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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ,. APPLICATION S <br /> (For Non-Transferable, Revocable, and Suspendable) SE PTAGE l <br /> ENVIRONMENTAL HEALTH PERMIT d <br /> LIQUID WASTE <br /> Applicatio i hereby m to car on business in the jurisdictional area of the San Joaquin Local Health District 0 <br /> _ Glp E S'F�PUIC�- Address <br /> N Business Name (DBA) <br /> ? Owner 7iC Address_ <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 0. s;--CR Emergency Telephone No. <br /> a Business Telephone No. <br /> -AContractor Licence No. . 36 3 9, <br /> L Applicants Name (Print) & Title �S T 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 /> 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 n <br /> No. of Chemical Toilets Stored v1 <br /> IF 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. ;W SANITATION PERMIT S�o� 'Q� <br /> Job Address/Location �S 1 E �- <br /> Owner G� Ufa Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT t� w <br /> K PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHER 5?elnfp <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 <br /> I Where Certified <br /> Operator Name <br /> a <br /> Plant Location Slaved <br /> ►[NbUnit ' <br /> Plant Capacity . 's d <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: 11Less Than 1,000 Sq. Ft., ElMore Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application andbthat the work will be done in accordance with San Joaquin County <br /> lations of'the San 6aquin Local Health District. <br /> ordinances, state laws, a and regu { <br /> k APPLICANT'S SIGNATURE <br /> f <br /> -4-FOR DEPARTMENT-USE-ONLY----' <br /> Fee Is Due: 11 ANNUALLY PER UNIT PE SITE ❑ EACH ❑ January 1 &Received By January 31 ❑"July 1 &Received By July 31 <br /> j� REMIT <br /> EXPLANATION iBILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EDATE DATE REMITTED AMOUNT <br /> � PL ! <br /> FEE `r�.. i ! t� 4K3- <br /> X _ r <br /> PRORATION - w <br /> PLUS ' ,� <br /> LTY \' <br /> V PENA - <br /> i <br /> OTHER t <br /> i <br /> y OTHER <br /> L7-% Mailed Delivered <br /> 10� t t.� <br /> i Received by � Date Receipt No Permit No. issuance Dat <br /> ! 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,'CA 95201 <br /> i APPLICANT`RETURN.LL COPIES TO: t ENVIRONMENTAL HEALTH PERMITISERVICES <br />