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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 "'$ S�PTAGE <br /> LIQUID WASTE <br /> Application is here made to caro usiness'n the juris 'ctional area of the San Joaquin LDeal H is t ✓` <br /> ,F, Business Name D Address <br /> Z Owner Address <br /> I -Firm Partners, Addr sses and Telephone Num ers <br /> i a Business Telephone No. Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> I L Applicants Name (Print) Title Date <br /> Please check Applicable Categ { -7 F i he Required I rmation l� <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH EHICLE) 1L}J <br /> I For July 1, June 30, 19 Disposal Sites , <br /> I Description(Make/Yr., Color) IM <br /> Serial.No. w �� CAL. License No. CAL. Liccnse Renewal No. <br /> rI <br /> Capacity M Gal., Weights & Measures No. ! <br /> Equipment Parking Address <br /> i 2. ❑ PUMPER YARD - "+ <br /> For July 1, June 30, 19 �} 4f <br /> No, of Vehicles Stored a - '` 41, <br /> No. of Chemical Toilets Stored <br /> 3. ElPERCOLATION TEST X111 <br /> R.S. or R.C.E. Name �I R.S. or R.C.E. No. <br /> l Test Location IM <br /> _ Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br />! Job Address/Location f <br /> Ae, <br /> EPTIC TANK ❑ CESSP OL LEACHING FIE SEEPAGE PIT PACKAGE PLANT <br /> ERMANENT ❑ TEMPORiARY ❑ NEW REPAIR ❑ OTHER <br /> - - <br /> I 5. ❑ CHEMICAL TOILETS For�JLily 1, --June- 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units iM 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 �M No. Units Served IN, <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. kt., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEAN ING,,Chemicals Used/Amount/Mo. <br /> .ti <br /> I <br /> . y i <br /> I hereby certify that I have prepared this application a t the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, f nd rules an g ns of th n daquin Local a! istrict. i <br /> x <br /> APPLICANT'S SIGNATURE X r <br /> I <br /> �c a <br /> � R i <br /> FOR DEPARTMENT USE ONLY <br /> IiNII <br /> Fee Is Due: 0I ANNUALLY II❑ PER UNIT PER SITE ❑ EACH ❑ Januar <br /> y 1 8 Received R Jan'ua y 1 ❑ July 1 . rved 6Y Y Jul 31 <br /> BASE EXPLANATION -BILLING REMITTANCE REMITA UN E CHECKED ! <br /> . DATE DATE RE I AMOUNT <br /> o <br /> FEE �C -5 11 <br /> LESS <br /> PRORATION <br />' PLUS <br /> x PENALTY <br /> OTHER <br /> OTHER i1 ::�v <br /> f <br /> r H <br /> Received by' Date g' Receipt No Permit No. I suan a Date Ma' d Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O. STOCKTON,CA 95,201 :l <br />