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mppncanons wuI oerrocessea wnen suornttteorropenylUompletea. Be Sure !o SignTheApplication. <br /> APPLICATION 0 <br /> (For Non-Tran storable Revocable and Suspendable) $rPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 3 LIQUID WASTE <br /> Applica ion Is her o car o u ness in ua risdictional area of th J uln L a Health Disjri <br /> I. Business Name (DBA) y made t , Address � �7 <br /> •Owner I iAddress <br /> Firm Partners, Addresses and Teiepho4e Numbers <br /> a Business Telephone No. 49'-94c 0- Emergency Telephone No, <br /> Contractor Licence No. 'S_4__ <br /> -Applicants Name (Print) �.? Titl �— Date ` <br /> s <br /> Please check Applicable Category (1-7)-and FI 11 In the Required Informatton <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For Juty 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL.Pcense No. CAL. License Renewal No. - <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address i - <br /> 2.-❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored ) <br /> No. of Chemical Toilets Stared i <br /> i 3. 17 PERCOLATION TEST <br /> # R.S. or R.C.E,Name R.S.or R,C.E. No. <br /> Test Lo ) Test bate/Time <br /> 4. �S NATATION PERMIT 3 <br /> 'Job Address/ ocatlon �� <br /> s t D❑wrer �, _..__.-.-.. Address 2SA A" <br /> AL-1• <br /> SEPTIC T <br /> TANK ❑ CESSPOOL I D LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY, ❑ NEW D REPAIR XOTHERA$AOboN ' �L 0`rAAJ1< <br /> ' 5. © CHEMICAL TOILETS For July,1,-June 30, 19 11 <br /> Type Construction Disposal Site f <br /> t No.of Units Equipment Storage/Cleaning Location(s) <br /> t 6. 0 PACKAGE TREATMENT PLANT. For July 1, -June 30, 19 <br /> � Operator Name Where Certified <br /> Plant Location <br /> } Plant Capacity ` ) No. Units Served <br /> T. ❑ LAUNDRY For July 1, June 30, 19 <br /> SIZE; ❑ Less Than•1,000 Sq, Ft., 1❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> .A <br /> t ~ <br /> F I hereby certify that.lprepared this o pplication ard that t e work will be done in accordance with San Joaquin County ( j <br /> ordinances, state lawftoqa and're lations of Xan Joe" <br /> uin Local Health District. •-•- , E <br /> APPLICANT'S SIGNATURE <br /> (( s <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑,ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH1, ❑ January 1&Received By January 31 ❑ July 1&Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> AMOUNT DUE CHECKED <br /> DATE GATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS qq <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Rocelpt N;. Permli No Is8uanC0 ate, Mailed Delivered <br /> APPLICANT—RETURN All COPIES TO: ENVIRONMENTAL HEAL 11MIT/StRVICES trn1 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON•C 5 <br />