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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheAppiwation. I <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) $EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is ere ade to carry on buWiess in the jurisdictional area of the an Joilquin Local Health District p <br /> N Business Name (DBA)12 Address _ <br /> z Owner Address f <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. '�� " �Q',1 Emergency Telephone No. , f <br /> a 1 <br /> Contractor Licence No. 7, �� r8 t <br />�. L Applicants Name (Print) T ., Titl ��� /�-7Ca� Date { <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ( j <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> I Serial No. CAL. License No. CAL. Licc;se Renewal No. <br /> Capacity- Gal.,Weights & Measures No. <br /> Equipment Parking Address H T <br /> 2. ❑ PUMPER YARD <br /> June 30, 19 <br /> For July 1, <br /> f <br /> No. of Vehicles Stored 4 <br /> No. of Chemical Toilets Stored <br /> ' 3. ❑ PERCOLATION TEST <br /> I _ R.S.or R.C.E. Name R.S. or R.C.E. No. ' I <br /> Test Location Test Date/Time i <br /> 4. E SANITATION PERMIT I <br /> Joie Address/Location OQs99 1ti C 1 <br /> t Owner Address � S <br /> ❑ SEPTIC TANK ❑ CESSPOOL ©'LEACHING FIELD �8 SEEPAGE PIT ❑ PACKAGE PLANT <br /> L C-PERMANENT ❑ TEMPORARY ❑ NEW CIREPAIR ❑ OTHE=R o1� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal,Site - `g <br /> No. of Units Equipment storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> iWhere Certified <br /> L Operator Name I <br /> ( Plant Location <br /> l Plant Capacity No, Units Served i <br /> Ip 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> r SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.Ft. k <br /> r i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> l <br /> A <br /> hereby certify that 1 h ve prepared this application a Y that the work will be done in accordance with San Joaquin County <br /> r ordinances, state laws d rules ago regulati , oft .San J aquirl Local Health District. <br /> APPLICANT'S SIGNATURE <br /> O� <br /> a FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &AR4veA A January 31 ❑ July 1 &Received By'July 31 ' <br /> REMIT <br /> BASE - EXPLANATION BILLING RE TTANCE AMOUNT DUE CHECKED <br /> DATE ATE EMITTED AMOUNT <br /> k FEE <br /> LESS 4 <br /> PRORATION _ <br /> PLUS .I <br /> PENALTY <br /> r OTHER ' <br /> OTHER <br /> ' Received by Date Receipt No. Permit No Issua a Da a iled Delivered <br /> APPLICANT—RETURN-ALL COPIES TO: - ENVIRONMENTAL HEALTH_P,ERMIT/SERVICES - 1601 E..HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 95201 "" <br />