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' FLppnaanonsWillBe ProcessedWhen Submitted Properly Completed_ Be Sure To Sign Thi3,4lipllt+tlian. <br /> 0. 'J APPLICATION t. <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> " <br /> LIQUID WASTE 7 911Q41 <br /> g_. <br /> Application is ereby made to carry on business in the jurisdictional area of the San Joaquin Local Heallil()istrict <br /> Business Nam DBA) ! S 5 Address <br /> z Owner ; <br /> a Address <br /> t Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 9-/ Emergency Telephone No. -- <br /> Contractor Licence No. 5-1 41 ----- <br /> L Applicants Name (Print) # 1A.r_<'I a Title <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1 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 /> I <br />! Equipment Parking Address <br /> 2. ❑ PUMPER YARD . i <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. R. E. N <br /> Tet Location I Test Date/Tim <br /> 4. SANITATION PERMIT r <br /> Job Address/4ocation <br /> Owner �� ddress – <br /> ❑ SEPTIC TANA ❑ CESSPOOL LEAC LD ❑ EP T ❑ PACKAG PLANT <br /> 0 1iPERMANENT E] TEMPORARY El NEW 11R IR OTHER S �( j O X /O F-1I t-e12 <br /> 5. CHEMICAL TOILETS For July 1,-June 30, 19 J <br /> Type Construction j Disposal to <br /> No. of Units Eq nt Stora a/Clea <br /> g g Locations) <br /> 6. ❑ PACKAGE TREATMENT PLA F r y 1, -June 30, <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity -----` - 1 <br /> No. Units Served { <br /> 7. ❑ LAUNDRY For July 1, -Jun j --- <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 q. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Am O. <br /> I hereby certify that I have prep th' iication and that the work will be done in accordance with San Joaquin County ' <br /> ordinances, state laws, and rules a e ions of the n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY J <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 3111 <br /> I' <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> 1 DATE DATE - REMITTED AMOUNTOUE CHECKED <br /> AMOUNT <br /> EFCE ` <br /> { <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ,i <br />