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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) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> "Business Name {DBA) Addressz <br /> z Owner A P_I. �� _ Address 917/2 <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> Zi <br /> IL Emergency Telephone No. <br /> CL Business Telephone No. g y <br /> 1 Contractor Licence No. - <br /> Applicants Name(Print) Title Date <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 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No, <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets 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 PERMIT <br /> Job Add r ss/Locatign <br /> Owner e,G I C, Address <br /> ❑ SEPTIC T K 11 CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT xPACKAGE❑ PLANT❑ PERMANENT E] TEMPORARY 1:1NEW ❑ REPAIR OTHER FE'S -4 r <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <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 /> j I hereby certify that I have prepared.this app kation and that the work will be done in accordance with San Joaquin County <br /> ordinances, slate laws. „ <br /> VC <br /> YAPPLICAINT'S SIGNATURE X Title u' Date <br /> �3 <br /> FOR-DEPARTMENT USE ONLY <br /> Fee 1s Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑-January 1 S Received By January 31 ❑ July 1&ReceivedBnAyl July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> i <br /> DATE DATE REMITTED AMOUNT <br /> 4 <br /> FEE <br /> Ss <br /> R <br /> tION , <br /> OTHER <br /> OTHER <br /> r <br /> ' Permit No. Issuance Date Mailed Delivered <br /> Received by Date Receipt No <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2048 STOCKTON,CA 95201 <br />