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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 /> ` ENVIRONMENTAL HEALTH PERMIT SEEPAGE <br /> LIQUID WASTE <br /> Application is he eby made to carryon business in the jurisdictional area of the Joaquin Local Health District <br /> FBusiness Name (DBA) ,�. .�i_ ��i 41- </z ddrgss 24' <br /> a Owner_ Address ��l j> <br /> Firm Partners, Addresses and Tel phone Numbers JVT '9 <br /> a, Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. } <br /> LApplicants Name (Print) // Title DateJZl <br /> I 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 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> - - <br /> 2. "❑PUMPER YARD - " o x.. �,� . ,...�-� �,..-.. �...- - �•-- <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored f� <br /> 3. ❑ PERCOLATION TEST } . <br /> R.S.'or R.C.E. Name R.S. or R.C.E. No. <br /> TestLocation Test Date/Time <br /> I 4. ❑ SANITATION PERMIT <br /> Job Address/Location r G� /.}. 1-7 <br /> ��- ' Address ."� T i AGt <br /> k tet SEPTIC TANK ❑ CESSPOOL j LEACHING FIELD El SEEPAGE PIT ❑ PACKAGE PLANT, , <br /> f ❑ PERMANENT ❑ TEMPORARY El NEW ❑ REPAIR ❑ OTHER <br /> k <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site 7 <br /> No. of Units Equipment Storage/Cleaning Locations) €� <br /> 6. P PACKAGE TREATMENT PLANT li 1, -June 30,'-19 <br /> Operator Name Where Certified e <br /> Plant Location _ t <br /> Plant Capacity No. Units Served <br /> 7. El LAUNDRY For July 1, -June 30, 19 + - <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than.1:,D00 Sq. Ft. ( '? <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. a <br /> I hereby certify that I have prepared this application and that the-work will be done in accordance with San Joaquin County <br /> ordinances, state laws"and rules and ulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X' <br /> I <br /> I -° <br /> 77T <br /> t <br /> . - - — ,.,..- FOR-DEPARTMENT-USE ONLY <br /> .-�� r <br /> Fee Is Due:`❑ ANNUALLY . ❑ PER UNIT. " ❑ PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 { <br /> REMIT <br /> { <br /> BILLING REMITTANCE $ - <br /> S r BASE EXPLANATION AMOUNT DUE .:CHECKLO <br /> DATE DATE REMITTED 'AMOUNT <br /> • J <br /> 'FEE ,re { <br /> s <br /> LESS j <br /> PRORATION f <br /> i <br /> PLUS <br /> PENALTY F <br /> �,. OTHER - _. _ ^y'- i,3 �-�•..-� n -� s_�. <br />' OTHER <br /> Received by -- Date t Receipt No- Permit No. Issuarke Date Mailed Delivered - ] <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95 <br />