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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 7 APPLICATION <br /> _SQ (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 /> H Business Na a (DBA) Address <br /> i Owner J7�/�� - -- —.���-7 <br /> —.B�t°i"/ __ Address�w1�,� z�- — -�-- <br /> 7u Firm Partners. Addresses and Telephone Numbers <br /> cBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. - -- ------ <br /> Applicants Name (Print) ' Title �+�!EiXY�,�lt�/ - - <br /> 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 Capacity <br /> CCAL. License No. _- CAL. License Renewal No <br /> Capacity __-- -_ Gal.,Weights&Measures No. _ — <br /> Equipment Parking Address _ <br /> 2. ❑ PUMPER YARD - - —For July 1, - June 30, 19 <br /> No of Vehicles Stored _ <br /> No of Chemical Toilets Stored_ — --- <br /> 3. 0 PERCOLATION TEST -- - - --- - -- - --- -- - _ — <br /> RSaw R.C.E. Name p-V <br /> _ R00pr R.C.E.No Adl <br /> �— <br /> Test Location G 7�2teL�! ir' Test Date/Time Z / <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 /> 0 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. C1 LAUNDRY For July 1, -June 30, 19 <br /> SIZE ❑ Less Than 1,000 Sq Ft., ❑ More Than 1,000 Sq. Ft (9 <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 Coin <br /> ordinances, state laws <br /> APPLICANT'S SIGNATURE Titlevl � �/7�'►�r Date <br /> — a <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is DUB: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE- ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE GATES yy REMITTED AMOUNT <br /> FEE V <br /> LESS ---- -- <br /> PRORATION 74 C�1 <br /> PLUS - ----- --- - -- -- -- <br /> PENALTY <br /> OTHER - --- - - --- -- — -- -- --- <br /> OTHER -- --- — - -- ---- <br /> 221=C).�- C1.2 <5'j/51- <br /> Received by Date Receipt No Permit No issuance Date Mailed Delivered <br /> APPLICANT-RETJMN ALL COMES TO: ENVIRONMENTAL HEALTH PERMIT!SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />