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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,find Suspendable) S 1'TAG <br /> ' ' `ENVIRONMENTAL HEALTH PERMIT <br /> SY�J `�+ LIQUID WASTE 4 <br /> Application is reby made to ar -bn business in the jurisdictional area of the San Joaquin Local eaith riot <br /> ,r Business Name (DBA 1kAddress <br /> z Owner_.. Address- d <br /> u f=irm Partners, Addresses and Telerhone\Numbers- <br /> 0. <br /> um,bers <br /> a Business Telephone No. (—/ �; `� - •••• Emergency Telephone No.. <br /> -J Contractor Licence No. t �t ' <br /> Applicants Name(Print) � �;�- ,. ,•Tltle = M w Date - -_ <br /> Please check Applicable Category[1-7) and Fill in the .equired Information- <br /> V_ <br /> nformation,y x «., h •,k� :xt <br /> 1. 11 PUMPER VEHICLE PERMIT,REGISTRATION (FOR EACH VEHICLE) o <br /> For July 1, - ` -June 30, 19 ==' - Disposal Sites <br /> Description(Make/Yr., Color) IM <br /> Serial No. - r GAL. License No. CAL. License Renewal No. <br /> Capacity _ Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD i j� ;� �•`�'� � i <br /> 0 <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.G.E. Name ` ' y R.S. or R.C.E. No. + <br /> I <br /> .Test Location' '' ��- 1 Test Date/Time 'f <br /> 4: ❑ %-'SANITATION PERMIT "� � �`'�'_• � � <br /> Job Address/Locatio <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CE SPOOL 21 LEACHING FIELD E SEEPAGE-PIT ❑ PAICKAGE PLANT <br /> PERMANENT ❑ TEMP6ARY ❑ NEW REPAIR ❑ OTHER F ' <br /> ❑ CHEMICAL TOILETS For July 1, -June,30, 19 b..* <br /> Type Construction 1 ~-� • --^� ~~bisposal-Site . <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 191 I n <br /> Operator Name Where"Certified <br /> Plant Location <br /> Plant Capacity- G--UUnits Served r <br /> 7. 11 LAUNDRY For July 1 June 30, 19 -# <br /> I 1 ; <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,: _❑ More Than 1,000 Sq. Ft. _ 1 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Ma. e <br /> .: i. <br /> i <br /> I hereby certify that I+have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state I wsj and.r nd regulations of the San Joaquin focal Health District. t <br /> APPLICANT'S SIGNATURE X / <br /> 14 <br /> , I <br /> -FOR DEPARTMENT USE.ONLY r r 4 <br /> Fee IS Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE - ❑ EACH ❑ January 1 &Received By January 31 13 July 1 &:Received By July 31 ' <br /> BILLING REMITTANCE. $ 3 REMIT <br /> BASE I� EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT - <br /> FEE <br /> LESS '! <br /> PRORATION li` - <br /> oe <br /> PLUS i <br /> OTHER <br /> °Ip <br /> l <br /> ,OTHER <br /> z ZA, �_. .. <br /> 71 Az2 <br /> Received by Date I11 , Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COF45 TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boni 2009 STOCKTON,CA 95201 - <br /> i \A <br />