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APPLICATIONr <br /> (V%w Non-Transferable, Revocable, and Suspendable✓ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application Is hergby Made to carry on busitless in the jurisdictional area of the Sap Joa rn Local Health latrict <br /> 3usiness Nafne (DBA) � f c <br /> Address. ` �... * '✓ r �' c 1 <br /> Dwner / Address r, - --- - - <br /> m Partners, Addresses and Telephone Numbers 422.- J�f'I_rE . 17 IV <br /> 3r)siness Telephone ... Emergency Telephone No _ <br /> ,ontractor Licence No. - <br /> applicants Name (Print) Title _. c ��.,+ Date <br /> >lease check Applicable Category (1-7) and Fill in the Required Information <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> or July 1. June 30, 19 -. - Disposal Sites -- - - --- - <br /> 7escription(Make/Yr., Color) <br /> 3erlal No. _ _- CAL. License No. -_ --_- .-.. - CAL. License Renewal No. <br /> rapacity _ 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 /> a,S. or R.C.E. Name R.S. or R.C.E. No. _ <br /> Test Location _ . _—.. Test Date/Time <br /> 4, 2SANITATION PERMIT <br /> Job Add r ss/Location <br /> Owner � P Address <br /> ❑ SEPTIC TANK Cl 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 /> 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 /> SIZi ❑ Less Than 1,000 Sq. Ft„ ❑ More Than 1,000 Sq- F1- <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - -- - - -- --- -- - = <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� a�n/d„regulation o fie an Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE}C / v -- - - <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE Cl EACH ❑ January i &Received By January 31 ❑ .hiky 1 8 Received By JL,;,J1 <br /> REMIT <br /> BASE EXPLANATION �� BILLING REMITTANCE $ Al DUE CHECKED <br /> DATF. DATE REMITTED AMOUNT <br /> FEE C _- --- -Cj <br /> LESS __j ; tr <br /> PRORATION <br /> PWS <br /> PENALTY <br /> O7HER I ^ <br /> OTHER <br /> -- <br /> i <br /> J <br /> ved by Dale ern 11 Ilss a c ❑al Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO', ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2909 STOCKTON,C 95ET'-Al <br /> 01 <br /> Kee b _ E ' { <br />