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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> < - APPLICATION <br /> - w <br /> (For Non-Transferable, Revocable, and Suspendable) j E <br /> ENVIRONMENTAL HEALTH PERMIT / SE.PTAGE <br /> LIQUID WASTE - <br /> i� <br /> Application is h re made to carry on business in the jurisdictional area of the San�aquin Local Health District <br /> Business Name (DBA) N Address C f <br /> aOwner Q Address ' <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 2t igl <br /> L Applicants Name (Print) l =� Title Date <br /> Please check Appl ci abii--Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICL•i'PERMIT REGISTRATION (FOR EACH VEHICLE) �J <br /> For July 1, June 30-,19, .r Disposal Sites <br /> Description(Make/Yr., Colo) } <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. T <br /> Capacity Gal.,Weights&Measures No. - <br /> Equipment Parking Address " <br /> 2. ❑ PUMPER YARD �`. UK <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 i R.S.orR.C.E. No. <br /> Test Location � Tent Date/Time <br /> 4. ❑ SANITATION PERMIT II <br /> Job Address/Location <br /> O..,wn � -Address <br /> 2 SEPTIC TANK C1CESSPOOL. C <br /> AHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW . [],REPAIR. - _.E1❑ OTH_ER 3 <br /> 5. ❑ CHEMICAL TOILETS For'July 1, -June 30, 19 ry 4 <br /> Type Construction Disposal Site . ; <br /> No. of Units F Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name i` Where Certified i <br /> Plant Location <br /> Plant Capacity No, Units Served r <br /> '. <br /> 7. El LAUNDRY For July�1---June . 4 '30,19'' <br /> SIZE: ❑ Less Than 1,000 Sq. Ft,, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. € <br /> 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,-an d-rules-and-regulatiQr)s-of the_San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> h FOR DEPARTMENT USE ONLY <br /> Fee Is Due:'0•ANNUALLY ❑ PER UNIT ❑ PER SITE 0 EACH ❑ January 1 &Received By January 31 ❑ Ju1y 1 &Received By July 31 <br /> BILLING R MITTANGE REMIT <br /> '% BASE EXPLANATION F. 5 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED - AMOUNT s <br /> FEE <br /> LESS <br /> PRORATION r <br /> PLUS —�^ - <br /> PENALTY <br /> OTHER <br /> iN <br /> OTHER <br /> y s, <br /> Received by Date Receipt Nw- Permit N?,,,- I suan e Date Mai a Delivered <br /> APPLICANT—RETURN ALL COPIESTO: ENVIRONMENTAL`HEALTH PERMIT/SERVICES ."-7601 E:HAZELTON AVE.,P.D.Bax 2009 - STOCKTON,CA 95201 - <br />