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Applications Will Be <br /> Processed When Submitted Properly Completed. Be Sure To Sign The Application. r_ - <br /> ` APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT '6�E!?TAGE <br /> LIQUID WASTE <br /> Application is hereby made o Cary on business in the jurisdictio al area of the San Joaquin Lac Health Qistriict/ <br /> rn Business N me (DBA) a�11 11� i S l!9? C �lLAddress . T7� ,W_ �iI+� 'j� <br /> z Owner-K. 4 C, � ` .i IAddress <br /> aFirm Partners, Addresses and Telephone Numbers S% e3D <br /> a Business Telephone Na. Emergency Telephone No. <br /> Contractor Licence No. <br /> IL 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 <br /> Description(Make/Yr., Color)' <br /> i Serial No. CAL. License No. CAL. License 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 <br /> Test Date/Time <br /> 4. SANITATION PERMIT € P <br /> Job Address/Location A/- <br /> Owner -lt9/3 ' e u e "` " Address a a 4r- f5 13 Q A—Y IQC e- C-,e� . <br /> SEPTIC TANK ❑ CESSPOOL BLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ( sj4 ,�� <br /> PERMANENT ❑ TEMPORARY g NEW 'El REPAIR 'y. ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30,'19 s <br /> Type Construction Disposal Site `- <br /> a <br /> No. of Unify Equipment Storage/Cleaning Location(s)' I <br /> 6. ❑ PACKAGE TREATMENT PLANT For.July 1, -June 30, 19 A <br /> Operator Name ( Where Certified <br /> k Plant Location <br /> Plant Capacity P Y 'No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> I SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <br /> i - <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, a d les and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X .. <br /> i FOR DEPARTMENT USE ONLY <br /> Fee IS Due:❑ ANNUALLY EI PER UNIT LPER SITE ❑ EACH ❑ January 1 &Received By January 31 <br /> 1:1 July 1 &Received By July 31 <br /> tREMITTANCE $ REMIT I <br /> BASE EXPLANATION BILLING AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Lk L.f 1✓� <br /> LESS <br /> PRORATION <br /> M <br /> PLUS <br /> PENALTY ' <br /> OTHER <br /> OTHER — <br /> r <br /> �APPLIC'ANT—RE;URN <br /> y ate - Receipt No. Permit No. - Issuance Dale Malted Deliverd <br /> ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1fi01 E.HAZELTON qVE.,P.O.Bol 20119 STOCKTON,CA 11111 <br />