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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sr <br /> APPLICATION - <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPT4GF <br /> LIQUID WASTE ` <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA) <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers Address <br /> a <br /> f <br /> a Business Telephone No. ql <br /> Contractor Licence No. Emergency Telephone No. .3 _ r <br /> a r <br /> L Applicants Name (Print) C' <br /> Please check Applicable Category Title G C f�- Date <br /> g ry (1-T)and Fill iri the Required Information <br /> 1. 11PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) O <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. <br /> Capacity CAL. License Renewal No, <br /> Gal., Weights & Measures Na. <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 I <br /> R.S. or R.C.E. Name <br /> Test Location <br /> R.S. or R.C.E. No.4. 11SANITATION PERMIT Test Date/Time <br /> Job Address/Locatio 11 1 — f /� <br /> Owner <br /> Address V <br /> SEPTIC TANK CESSPOOL ®`LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT 60 . <br /> ❑ PERMANENT ❑ TEMPORARY C NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 4 <br /> Operator Name v m <br /> Plant Location <br /> Where Certified r <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 tJ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo. y <br /> `J2�3��C '�2iC` Cpll3ht3CB:L — Z:O <br /> D' <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 regulations of the San J aquin Local ealth ' trict. <br /> APPLICANT'S SIGNATURE X <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ January 1 &Received By January 31 El July 7 &Received By July 37 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED 'AMOUNT DUE CHECKED s <br /> EEEAMOUNT <br /> -4 rl-A 10 -7 ga ;7-7-8j- 0 _ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY F <br /> I <br /> OTHER { <br /> OTHER 1) <br /> -3 6, ' (o,3_S <br /> eceived by Date Receipt No. Permit No. ~^ <br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Issuance Date Mailed Delivered - <br /> 7601 E.NAZELTON AVE:,P.O.Box 2009 STOCKTON;CA 9 - <br />