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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) f <br /> 1 � <br /> ENVIRONMENTAL, <br /> 'HEALTH PERMITSEPT4GE l <br /> LIQUID WASTE . <br /> Application is hereby made to carryon bu, ness in he jurisdictional area of the San Joaquin L al Health District <br /> OF Business Name (DBA)` \AL I N Wt L Address } <br /> z Owner��— 1-T r`.- !NLa Address7. <br /> Q k <br /> J Firm Partners, AddresseAaT�Iephone Numbers ' <br /> aBusiness Telephone Na -Emergency Telephone No. <br /> Contractor Licence No, <br /> a A Ilcants Name (Print) Title C_ Date p� <br /> [`:PP V <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 f At <br /> p .I <br /> Description(Make/Yr., Color) i <br /> Serial No. CAL. License No. �-- CAL License Renewal No. <br /> "Ca acit -Gal;Weights'&Measures Noa "" <br /> _ - - <br /> p Y ; <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July F.Y June 30 19 <br /> No. of Vehicles Stored <br /> �No. of ChemicalYToilets 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 PE MIT" <br /> JobAdd s/Location ETT <br /> y F <br /> Owner Address +-mi` - <br /> ❑ SEPTIC TANK ❑ CESSPOOL "LEACHING FIELD ❑�,j'SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW I�EPAIR -OTHER - r <br /> S 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19• { s 3 <br /> Type Construction Disposal Site �f <br /> ` <br /> No. of Units Equipment 9 E 9 <br /> t ui ment Stora a/Cleanln Location(s) ' ---- <br /> ._ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> E Operator Name - t - - - -- - Where Certified <br /> —Plant Location- a <br /> -Plant Capacity No. Units Served r w <br /> `7. 11 LAUNDRY For July 1, -June 30, 19 - <br /> ,SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. F~ <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.S n;Joaquin County <br /> ordinances, stat. la and rules regulations- •the-San-Joaquin"L';ocal.Health District. <br /> k �1 <br /> "APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY: <br /> ' January 1 &R iv d By January 31 ❑ July 1 &Received By July 31 <br /> Fee Is Due: C1 ANNUALLY ❑ PER UNIT <br /> ❑'PER SITE EACH ❑ REMIT <br /> BASE _ EXPLANATION BILLING REMITTANCE $ AMOUNTDUE CHECKED <br /> " u+- -- -DATE -'- -DATE -REMITTED _ AMOUNT <br /> FEE 3• <br /> LESS <br /> PRORATION - <br /> I PLUS <br /> ` PENALTY <br /> OTHER <br /> OTHER <br /> �T <br /> Received b - Date ,,,_„ 'Receipt No., �,�. Permit No >f; f'� �`�..� issuance Date Mailed Delivered '... - , <br /> ,° -'_APPLICANT=RETURN ALL COPIES TOi ENVIRONMENTAL HEALTH PERMIT/SERVICES � - �'.¢1601� �HAZELTON AVE P.O:.Box 2009 STOCKTON, <br /> CA 952011 <br /> t <br />