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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION. <br /> (For Non-Transferable, Retrocable,'and Suspendable) SE P7AGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati is hereby m de arty on bus' ss in the jurisdictional area of the n.Joaqui LocW Health District:. . <br /> G` .. ..Irv` <br /> , Business Name (DBA) Address . <br /> z Owner ti• = Address <br /> J Firm Partners, Addresses and T lephone Numbers _ <br /> IL <br /> Business TelephoneyNo. _Emergency Telephone No. <br /> Contractor Licence No- <br /> L Applicants Name (Print) G .- Title ►f Z Date ` <br /> Please check Applicable Category (1-7)and Fill in the Requiredlnformation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1 June 30, 19 -_. _ - Disposal Sites-- �.,.�.._. -.. . ._ ... -._. �. ,.. <br /> Description(Make/Yr., Color) <br /> __ _ ;:.. ___--�--•- a .... - <br /> Serial No. CAL. License No. CAL, License Renewal No— a <br /> Capacity `Gal., Weights &Measures No. a <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD r —4 <br /> For July 1, June 30;19 <br /> No. of Vehicles Stored t "( 1 <br /> No. of Chemical Toilets Stored _ I <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name_ r '" �` R.S.or R.C.E. No. ' <br /> Test Location r n Test Date/Time.1 <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner y Address G • . <br /> ,ff SEPTIC TANK ❑ CESSPOOL- LEACHING FIELD ❑ SEEPAGE PIT- • ❑ PACKAGE PLANT <br /> IRPERMANENT 11-TEMPORARY ❑ N_EW REPAIR-_ C3 OTHER <br /> S. 11 CHEMICAL TOILETS For July 1, June 30,19 <br /> Type Construction _ -Disposal Site <br /> No. of Units 4 Equipment-Storage/Cleaning Location(s) ` <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name'' - .) - Where`Certified t <br /> 'Plant Location • _ <br /> Plant Capacity '~ YY No. Units Served^` k <br /> 7. ❑ LAUNDRY For July 1, YJune 30, 19_�',, <br /> SIZE: ❑ Less Than 1,000 Sq-?Ft. ❑'More Than 11;000 Sq. Ft. <br /> _ .. - <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. f <br /> ���- £ 1 1 <br /> I hereby certify that I have prepared this application aid that the work will be done in accordance with San Joaquin County- <br /> ordinances,,slate laws, and rules and re ula on of a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> t <br /> - FOR DEPARTMENT USE ONLY- <br /> I � <br /> Fee Is Due., ❑ ANNUALLY_ , ❑ PER,UNIT; ❑ PER SITE ,' El _ �❑ ONLY- <br /> January-14 Received'ByJanuary 31. _ ❑ July 1 &Received By July 31 <br /> _ •f REMIT <br /> BASE .�fEXPLANATION BILLING - REMITTANCE ' $ AMOUNT DUE CHECKED <br /> - - -r- - - - --DATE - - -rDATE REMITTED AMOUNT <br /> FEE— I— - •- - '- -", , t 4r _- <br /> LESS ; 4:.Ys <br /> PRORATION1 <br /> PLUS' { <br /> PENALTY <br /> OTHER t _. .... <br /> OTHER. <br /> ja <br /> ll <br /> Received by '..Date +� Receipt No. `e..t' . " No -� - ii . Issua a Mailed Deliveretl - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELT E-,P.O.Box 2009 STOCKTON,CA 95201 "' <br />