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Applications Will Be Proc -d When Submitted Properly Completed. Be Surf Sign The Application. <br /> N"' APPLICATION <br /> (For Non-Transferable. Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (PBA) Address <br /> Owner � U Address 2'/'g <br /> Firm Partners. Addresses and Telephone Numbers — -- -- - -- --- -- -- <br /> Business Telephone No - __ - ______—___ Emergency Telephone No. <br /> contractor Licence No <br /> 4pplicants Name (Print) ---- D Title (/ +'� / � 11r''^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 & Measures No - ---- <br /> Equipment Parking Address _. -------- <br /> 2. ❑ PUMPER YARD <br /> For July 1,___ ___ June 30, 19 __No. of Vehicles Stored <br /> No. of Chemical Toilets Stored- <br /> 3. <br /> tored__-3. PERCOLATION TEST ---- <br /> a.b..sp R.C.E. Name � iii O t`7 _ ______ R.C.E. No. 4- <br /> Test <br /> Test Location T Date/Time <br /> 4. ❑ SANITATION PERMIT --� <br /> Job Address/Location --- <br /> Owner _--_ Address --------- ----- — - <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br /> Type Construction _ Disposal Site <br /> No. of Units _ _ _ Equipment Storage/Cleaning Location(s) <br /> S. ❑ 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., ❑ More Than 1,000 Sq. Ft. <br /> DRY CLEANING, Chemicals Used/Amount/Mo. - <br /> y ,r <br /> +o � i N 2 <br /> I hereby certify that I have prepared this application and that the work ill be done in accordance th a Joaquin County <br /> ordinances, state laws 7- <br /> APPLICANT'S <br /> APPLICANT'S SIGNATURE X ------ �' �' Title _ -- Date �7v <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 6 Received By July 31 <br /> r ----- ----- ---T-- REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DA)TEE/ DATE REMITTED AMOUNT <br /> FEE ---- <br /> LESS <br /> PRORATION --- _---- --' ---- ---- —. <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> Recewed by Date Receipt No Permit No Issuance Date Mailed Dehvered <br /> APPLICANT—RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Boa 2009 STOCKTON.CA 95401 <br />