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Applications Will Be;Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> t APPLICATION <br /> f (For Non-Transferable,Revocable,and Suspendable) 5EPTAGE <br /> - ENVIRONMENTAL HEALTH PERMIT <br /> LIQU10 WASTE <br /> Application i erebymade 19 carryon bI,Asiness in the juris ctional area of the San Joaquin Local Health District <br /> NBusiness Name (DBA) r, Address <br /> a Owner dress !^ <br /> r <br /> rJ Firm Partners, Addresses and Telephone Numbers <br /> �� Emergency IL <br /> Business Telephone No. enc 9 Y Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name {Print) Title �'` � -- Date 7 � � <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) a+ <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. i CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights R 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 Address/Location d <br /> Address <br /> O�,wnr « �# <br /> 0 SEPTIC TANK ❑ CESSPOOL B'LEACHING'FIELD ❑ PACKAGE PLANT <br /> 131PERMANENT ❑ TEMPORARY ❑ NEW EPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site G <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 /> i 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 /> f ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> ) <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 laws, and rul and regulations of tfie- J quin Local Health District. <br /> s <br /> II. APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received-By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> t. <br /> FEE � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> C OTHER s' <br /> i <br /> - /V <br /> Received by Receipt No Permit NoIssuance DaMailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH'PERMIT/SER .,VICES 1601 E:HAZELTOM P.D.Boa 2009 STOCKTON,CA 95201 <br /> L � r <br />