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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. w <br /> APPLICATION <br /> (For Non-Transferable, Revocable,'and Suspendable) 51 PTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> i <br /> LIQUID WASTE <br /> Application Is reby made to car on business in the jurisdictional area of thQoSan Joaquin Local Heath District�S�Q <br /> Business Name (DBA t Addres <br /> z Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. �'�©7 Emergency Telephone No. ) <br /> Contractor Licence No. <br /> L Applicants Name (Print) ?7 Title r 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 & Measbres.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. + t�_ <br /> Test,,L n Test Date/Time ; <br /> 4. ?SAN P5AMIT O <br /> C <br /> Job Add ress/Locatior�� <br /> Ow�r [.tf� Address ✓� <br /> 0 SEPTIC TANK ❑ CESSPOOL LEACHING FIEt D EPAGE PIT ❑ PACKAGE PLANT <br /> IRPERMANENT ❑ TEMPORARY 0 EW ❑ REPAIR . ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 t C <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., ❑f More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 <br /> I hereby certify that l e prepared this application and th t the work will be done in accordan c�'w th San Joaquin County <br /> ordinances, state la n egulatio s f the S&IOJoaqZn Laval h District. (ti <br /> APPLICANT'S SIGNATURE t d <br /> FOR DEPARTMrT USE ON =y <br /> t,s <br /> Fee IS Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EA ❑'Ja ua Received By January 31 ❑ July 1 8 Received By July 31 <br /> ` ' - REMIT <br /> BASE EXPLANATION BILLIN R IT ""$ AMOUNTDUE CHECKED <br /> D 4 REMITTED AMOUNT <br /> FEE <br /> LESS \ <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER F r , <br /> OTHER <br /> l <br /> y <br /> Received by Date 4. Receipt No. Permit Na. Issuance Date Mailed Delivered <br /> i <br /> STOCKTON,CA 95201. <br /> APPLICANT—RETURN ALL COPIES TO: -.ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo 09 - <br />