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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) $EP7AGE <br /> f ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appiicatlon' rebx maAar on bush sin th ju isd'"tional area of the Sa aqu Local Health Distri <br /> OF Business Name( ) - <br /> ddress � 76' o <br /> Owner ddress-- - '-• - <br /> Firm Partners,Addresses and Telephone Numbers <br /> A. _� fits Emergency Telephone No. <br /> A.Business Telephone No. � C"1 i <br /> 4 <br /> Contractor Licence NO. X Z) ) <br /> LAppiicants Name(Print) Title Date -- 1 <br /> Please check Applicable Category(1-7)and Fill in the Required inf�ation -_ "4 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) U I, <br /> For July 1, June 30,19 Disposal Sites -->- <br /> Description(Make/Yr.,Color) <br /> Serial No. """ — CAL.License No.___. CAL.License Renewal NO. j <br /> Capacity Gal.,Weights&Measures No. <br /> Equipment Parking Address <br /> 2. Q 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 DateMme -- <br /> 4. ❑ SANITATION PERMIT <br /> r Job Address/Loc ion- _ <br /> `Ir O�w er Address. d"""''r'�' <br /> i� SEPTIC TANK ❑ CESSPOOL - LEACHING FIELD $PAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW [J"REPAIR ❑ OTHER od <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30,19 d <br /> r. Disposal.Site! r' <br /> Type Construction —Dis p <br /> No.of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30,19 <br /> Where Certified <br /> Operator Name <br /> Plant Location = _ <br /> Plant Capacity No.Units Served <br /> 7. 11 LAUNDRY For July 1,-June 30,19 <br /> SIZE: 13 Less Than 1,000 Sq.Ft., C3 More Than 1,000 Sq.Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/MO. <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 ru l regulations of San aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Feels DUe:0 ANNUALLY [3 PER UNIT ❑PER SITE EACH ❑ January 1&Received By January 37 ❑July t 6 Received BY July 31 <br /> REMIT <br /> EXPLANATION BILLING REMITTANCE $. AMOUNT DUE CHECKED <br /> BASE00 <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION In� <br /> PLUS <br /> PENALTY <br /> OTHER 6 <br /> i OTHER <br /> Dal cared <br /> Received by Dais RecelPt No. Perm tmtNNO. Iss ane Date Mallet <br /> S t6ei E.HAZELTON AVE.;P.O.Baa 7Aa9 <br /> •APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICESTOCKTON,CA 95ffiI <br /> ��- <br />