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Applications Will 13e Processed When Submitted Properly Gompletea. tse Sure I o slgn 1 ne Appucanon. <br /> APPLICATION <br /> -,jr Non-transferable, Revocable, and Suspendat. r �/ <br /> ENVIRONMENTAL HEALTH PERMIT 5: <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 (DBA) _�`_��1,;.f , Address�+ <br /> aOwner--_ Vic= !!q-z. 4 L� — , Address <br /> aFirm Partners, Addresses and Telephone Numbers — <br /> a. Business Telephone No. - <br /> —�-� �--��� _ Emergency Telephone No. _ <br /> Contractor Licence No. <br /> L Applicants Name (Print) - c Title W-z � Date <br /> Please check ACategory <br /> licable Cate ory ( <br /> PP g 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 <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 Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner if L /r_ ", �L/ -_ Address �_ !Y <br /> SEPTIC TANK ❑ CESSPOOL PCEACHING FIELD ❑ SEEPAGE= PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER 4: <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 S <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., ❑ 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 rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X -- <br /> C'9- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due_ ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> --- ---- - --- _- REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS _ <br /> PRORATION <br /> PLUS <br /> PENALTY JN <br /> OTHER - — <br /> �. <br /> OTHER <br /> ---- <br /> Received by Date Receipt No Permit No Issua ce Date M iled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1607 E.HAZELTON AYE., .Box 2009 STOCKTON,CA 95201 <br />