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Appimatlons wus lieProcessed WhenSubmitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> t4,Non-Transferable, Revocable,and Suspendable, <br /> ENVIRONMENTAL HEALTH PERMIT 5 PTAGc <br /> LIQUID WASTE <br /> Application is hereby 6atcle toccarry on.busi.pe s In the jurisdictional area of the Saq Joa Local Health strict <br /> f <br /> r <br /> Business�y e (DBA) _.�_` f - r �- Ad cess "L / <br /> a Owner- <br /> Address -___4 <br /> J Firm Partners, Addresses and Telephone Numbers _.� I-1E ` 4/_' If// <br /> Q. Business Telephone No. 1p_�-, _ -. -_ Emergency Telephone No. <br /> Contractor Licence No. , -� f —__- <br /> Applicants Name (Print) �� cT -_ Title -jC CIJ-A)-+__ . _ Date 12 �f <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 -_--- <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 /> c/ <br /> Job Addr ss/Location --15-25—d <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 'd <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <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: <br /> 9 -SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> L <br /> I hereby certify that I have prepared this applic �n and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and an egulatio e an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 /> i — — REMIT— <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION � AMOUNT DUE CHECKED <br /> j DATE DATE REMITTED AMOUNT <br /> FEE -- --- �----�- -- --- -------- -- - O� <br /> LESS �„ \ <br /> PRORATION <br /> PLUS <br /> PENALTY --_--� _ --- -_- — - <br /> OTHER ' t <br /> OTHER- - - - - -- -- - --- . <br /> Received by Date Receipt No. - Permit No. Iss aric4 MtOMailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTDN AVE..P.O.Box 2009 STOCKTON,C <br /> /p 95201 <br />