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Applications Will Be Pressed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> -- APPLICATION J,o(g <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati n is hereb made t .cacry o bu iness in the Jurittdic onal area of th San oaquin ocal Health istrict <br /> r yy s <br /> Business Name (DBA) J r�e i_��,SQG/aRN Address <br /> aOwner Thu_"S_ -- --- -- Address �/ 1 f _ L,Q/1 C <br /> Firm Partners, Addresses anq Telephorle Numbers_44 3" 26.2 <br /> aBusiness Telephone No. 3 � Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) ��u� y � Title IQ th _ Date 1— •�_____ <br /> Please check Applicable Category (1-7) and Fill In the Required Informatlon <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 d, 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. !(! OLATION TEST -7R.S. .0 . N�am`e per,- Ce ([ _ R.S. or� NO. 17 s <br /> Test Location �T�_L �� Q /lC Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <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 <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, 1g__ <br /> SIZE <br /> g— <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- /4-/yy� f <br /> APPLICANT'S SIGNATURE X �"" '_ _ Title -en _ Date <br /> - c <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ Juiy I a Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION AMOUNTDUE CHECKED <br /> DATE DATE REMITTED <br /> _ _ l AMOUNT _ <br /> FEE ` Z 2-10' 0 �9 <br /> LESS <br /> PRORATION <br /> PLUS —----- - ---- — — -- — --- - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> RecA.A'y Dale Receipt No Permit No Issuance Date Mailed Delivered S-- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20M STOCKTON.CA 95201 <br /> —-- <br />