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ApplicationsWill BeProcessedWhen SubmittedProperly Completed. BeSureTo SlottThoApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> r' ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE ? <br /> Application is hKDby made ar on business in the jurisdictional area of the Joa Local Health District <br /> rn Business Name �) d Address / J�-'-a <br /> aOwner Address �? - <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. — 477�_-e l U --- - Emergency Telephone No. <br /> Contractor Licence NO. / <br /> Applicants Name {Print) ; -� f--•� na �l Title - __ Oate <br /> Please check Applicable Category,(1-7) and Fill in the_Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) f� <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL, License NO. CAL. License Renewed No. <br /> Capacity ti Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> i <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> f <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test ocation Test Date/Time <br /> 4. W SANITATION PERM n <br /> Jot Address/Lo 'on ,- � <br /> 117 <br /> O ner catAddress �� <br /> SEPTIC TANK ❑ CESSPO L LEACHING.FIELD SEEPAGE PIT ❑ PACKAGE I}LANT <br /> PERMANENT ❑ TEMPORARYEW C3 REPAIR El OTHER <br /> 11 CHEMICAL TOILETS For July 1, -J�30, 19 <br /> Type Construction Disposal Site u <br /> No. of Units Equipment Storage/Cleaning Location(s) _ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certitlad <br /> ---.- <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. ----.-- i <br /> I hereby certify that I have preps is application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule regulati s of the SaR J tITin Loca ealth District.. <br /> APPLICANT'SSIGNATURE X <br /> I <br /> FOR DEPARTM'IENSE ONLY <br /> ) <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT []'PER SITE ❑ EACH ❑ January 1 &Received By January 31 LJ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION <br /> BILLING REMITTANCE $ <br /> � AMOUNT DUE CHECKED 1 <br /> 11 DATE DATE REMITTED AMOUNT <br /> FEE <br /> '--t <br /> LESS / <br /> PRORATION <br /> PLUS <br /> PENALTY— <br /> ., <br /> OTHER ! <br /> OTHER <br /> Received by Date Receipt No. Permit No. as-ince ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br />