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d Properly <br /> Applications Will Be Processed When SubAPtteeLICATIONpletea. tseaura r� ��y- <br /> (For Non-Transferable,Revocable, and Suspendable) p gEp(AGE <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> LIQUID WASTE <br /> Application is ereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Address— cep <br /> yBusiness Name (DBA) _ Address <br /> aOwner �� T - <br /> 0 Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> aBusiness Telephone No. ri <br /> Contractor Licence No. Title K' N�'� Date <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION Disposal EACH <br /> H VEHICLE) <br /> For July 1, June 30, 19 <br /> es <br /> Description(Make/Yr., Color) CAL. License Renewal No, <br /> Serial No. GAL. License No. <br /> Gal.,Weights & Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July i, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored ' <br /> 3. ❑ PERCOLATION TESTt ' <br /> R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location M-"P <br /> 4. ❑ SANITATION PERMIT d <br /> Job Address/Locatio -- 1 <br /> Address <br /> OwnerElPACKAGE PLANT <br /> `1YSEPTIC TANK C1 CESSPOOL Ij�CEACHING FIELD 11 SEEPAGE P17 ❑ OTHER <br /> E] PERMANENT 11 TEMPORARY ❑ NEW 13 REPAIR s <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction _ Disposal Site _ <br /> No. of Units Equipment Storage/Cleaning Ldcation(s) --- <br /> g. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 A 6� <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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. <br /> e <br /> I 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, and rules and r gut tions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> • <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY C] PER UNIT ❑ PER SITE ❑ EACH ❑ January t eceived By January 31 July 1 8 ReceivedREMIT <br /> uiy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> 1</5 <br /> FEE ` <br /> LESS _. <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Permit No Is an Date Mailed Delivered <br /> RReceipt No. <br /> Received by Date 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT=RETURN ALL COP1E5 TO: ,ENVIRONMENTAL HEALTHPERMITlSERYICES <br />