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Applications Will Be Processed When. Submitted Properly Completed. be Sure Io Sign Ine Application. <br /> 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 S n Joaquin Local Health Distuct <br /> Business Name (DB <br /> A) i u�c•„' it-�-f'> <br /> -E ' �T ?�' Address <br /> z Owner Y :-v� �r�— 3 -d e`� � Address _�� <br /> Firm Partners, Addresses and Telephone Numbers <br /> awBusiness Telephone No. — j `D S� Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> Applicants Name (Print) TitleDate <br /> Please check Applicable Category�(1-7) and Fill in the Required Information U <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 /> r2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> y3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E.No. <br /> Test LXation Test Date/Time <br /> 6-4. 10 SANITATION PERMIT <br /> Job Address/Location E ' <br /> Ownerf Address r <br /> `❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ,�, SEE AGE PIT ❑ PACKAGE PLANT d <br /> 11 PERMANENT ❑ TEMPORARY 11 NEW L�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 /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> 6 Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> `SIZE: ❑ Less Than 1,000 Sq. FL, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r. <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 r 'Glations of the Sa qu n Local Health District. <br /> yAPPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONL ' <br /> Fee IS Die: ❑ ANNUALLY 1-1 PER UNIT I PER SITE 11 EACH ❑ Jary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REM ANCE $ <br /> ` BASE EXPLANATION DATE ATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S! <br /> LESS <br /> ` PRORATION - <br /> PLUS <br /> ` PENALTY <br /> OTHER – — <br /> OTHER �Received oy Date Receipt N , <br /> L i t Permit No is ance to Mailed Delivered <br /> No <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT:SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201 <br />