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<br /> Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Appiicaflgn
<br /> 'APPLICATION s M
<br /> (For Non-Transferable,Revoble;and Suspendable)
<br /> ca
<br /> ENVIRONMENTAL HEALTH PERMIT SePT,aGE
<br /> LIQUID WASTE
<br /> Applicafi hereby ode to on'busi ess in the jurisdictional area of the Se Joao in Local aith Distrlc
<br /> rOw' nets' Name{DeA} r Address 0��
<br /> Owner Address
<br /> Firm Partners,Addrbsses and Telephone u t)rs
<br /> Business Telephone No. $ Emergency Telephone No '
<br /> 4 Contractor Licence No. _
<br /> L Applicants Name(Print) Title Date
<br /> Please chock Applicable Category(1-7)and Fill In the Required Informa:Eon
<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. ...�._,.,. �...,._,..._r._.�..,,,__ �..-. _...._....,-._..,_...-_.....-._.._.,_.
<br /> CAL.License No. CAL."License'Renewai'NO.
<br /> w-Capec€ty Gal.,Weights&Measures No.
<br /> Equipment Parking Address
<br /> ❑ PUMPER YARD
<br /> For July 1, June 30.19
<br /> i
<br /> No.Of Vehicles Stored .
<br /> -No.of Chemical Toilets Stored
<br /> „3,..-❑ PERCOLATION TEST
<br /> R.S. .r R.C.E,Name R.S.or R.C.E.Na._
<br /> }`Test Location Test Date/Time
<br /> 4.' ❑ SANITATION PERMIT
<br /> Address/Location C
<br /> Owner Address
<br /> 'SEPTIC TANK, ❑ CESSPOOL X LEACHING FIELD ❑ SEEPAGE PIT ❑.PACKAGE PLANT
<br /> ❑ PERMANENT. ❑ TEMPORARY X NEW ❑ REPAIR ❑ OTHER
<br /> '::5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19_
<br /> :Type Construction Disposal Site
<br /> ND.of Units: Equipment Storage/Cleaning Location(s)
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30,19
<br /> Operator Name. ' Where Certified
<br /> F Plant Location
<br /> ,_!.,Plant Capacity No.Units Served
<br /> ?r 7..,❑,LAUNDRY For July 1,-June 30,19
<br /> '`SIZE; ❑ Less Than 1,000 Sq,Ft., 13More Than 1,00C Sq.Ft.
<br /> =`.❑ DRY CLEANING,Chemlcals 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 and r lat' s of then Jo ui�t Local Health District,
<br /> "APPLICANTS SIGNATURE X
<br /> FOR DEPARTMENT USE ONLY
<br /> r„ _Fee Is Due:❑ ANNUALLY ❑PER UNIT .❑PER SITE ❑ EACH 11 January 1 d Received By January 31 ❑July"I d Received By JWy 31
<br /> -- ;BI REMITTANCE g REMIT
<br /> BASE EXPLANATION DATE REMITTED AMOUNT DUE 'CHECKED
<br /> - - AMOUNT
<br /> -�.. FEE - . -" -
<br /> LESS
<br /> PRORATION PLUSPENALTYOTHER --- -
<br /> Receirad try Date Receipt Na. permit No. Issuance Dato - .Mailed Dellrelad -
<br /> APPLrCW.--RETURN ALL COPIES Tp: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Ber no 'STOCKTON,CA 0520t
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