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r Applications Will Be 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 F; TIN AGE <br /> LIQUID WASTE ,��*� <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District "� a <br /> OF Business Name (DBA) Address 40 <br /> aOwner Address ' <br /> Firm Partners, Addresses and Teleph ne Numberso� ! ` <br /> 4 <br /> a Business Telephone No. Emergency Telephone No. <br /> Q <br /> 1 Contractor Licence No. <br /> L Applicants Name.(Print) A , /;e!a4l.jzoe_ Title ���a� Date <br /> Please check Applicabie 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. Q <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 `� �- s ' " <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 Test Date/Time <br /> 4. ❑ SANITATION PERMIT ; r <br /> Job Address/LocationIpli <br /> Owner 01I��= Address er s <br /> ©/SEPTIC TANK ❑ CESSPOOL OLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> El PERMANENT ❑ TEMPORARY ❑ NEW__- ❑ REPAIR <br /> -13OTHER <br /> 5. ❑ CHEMICAL TOILETS- For July,1,--.June 30; 19 ) <br /> Type Construction ' _ Disposal Site 1 <br /> No. of Units" '" Equip E_t Storage/Cleaning g cations)' 41 <br /> "•� -.R»-- .. .l <br /> 6. ❑ PACK-AGE TREATMENT PLANT For July 1, -June 30, 19 <br /> i <br /> Operator Name ' - Where Certified <br /> Plant Location ` <br /> Plant Capacity- No. Units Served �r <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19._ *�^-�^--F � �•�` �^ ate" <br /> SIZE: ❑'Less Than 1,000 S Ft., ❑ More Than 1,000 Sq. Ft. i <br /> Sq <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t <br /> c' <br /> I hereby certify that I haveprepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and reg tions of the San Joaquin LocafAealth District.'�°"'�'"�•F <br /> APPLICANT'S SIGNATURE X <br /> FOR.DEPARTMENT-USE ONLY <br /> Feels O.ue: ❑ ANNUALLY ❑ PER UNIT"^ E1—PER•SITE---�..-Q-EACH r°--�,.❑_January].&Received By,Januar ❑ July 1 8,Received By July 31 1 <br /> BASE EXPLANATION BILLING <br /> $ HE DATE <br /> DATE CE R $' ED AMOUNT DUE = CHECKED �! <br /> j \ AMOUNT i <br /> FEE +n <br /> ---LESS- <br /> PRORATION <br /> -PLUS <br /> PENALTY <br /> OTHER <br /> OTHER _ + <br /> Received by Date Receipt No. _ Permit No. Issuance Date Mailed. Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1661 L'HAZELTON AVE.;P.O.Box 2809 STOCKTON - <br /> ..-. -. _ - - - .. - .-x til a_^k •�.�"`:,5r.� ...' <br />