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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> H ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio e b made to car n b I ss in the jurisdictional area of the Sag uln Loo�l-lea t District <br /> r � « Address <br /> H Business Na DBA) ��"���`•.S �` � ��� �`"` <br /> Owner �'�' �� ��(e Address <br /> J Firm Partners, Addresses and Tel n�Num rs <br /> aBusiness Telephone No. M `'� r —�' Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date ) <br /> Please check Applicable Category (1-7)and Fill in the Required Information — <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites Pk <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccn,se Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT L� <br /> AlAe e-? Lv A -le ' <br /> Job Addre /Location /S 3�� S 0, � V �`�w CN <br /> O�er Miley cwc-vs Address SIT � <br /> L"J SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT 11 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW B REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 _ <br /> Type Construction Disposal Site l <br /> No. of Units Equipment Storage/Cleaning Location(s) SlMA. Iritis-) CLol,$4ye _ w n <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and hat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, n <br /> les and regulatios of the S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE Xh �� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE P{c � S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ` <br /> OTHER <br /> Imo- 1 s� 7,5 <br /> &I <br /> by D to Receipt No. Permit No. Iss nce to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH PERMIT/SERVICES 1601 E.HA NAVE.,P.O.Box 2009 STOCKTON,CA 95201 (' <br />