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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> For Non-Transferable, Revocable,and Sus ndable <br /> ENVIRONMENTAL HEALTH PERMIT �.� +� <br /> LIQUID WASTE <br /> Application s hereby made It arry Qn b siness in the jurisdictional area of the San Joaquin L e <br /> . Business Name (DBA) •^r Address <br /> Owner— <br /> my Address « + � �`w• - <br /> J Firm Partners, Addresses and Telephone Numbers �' --- <br /> 5. Business Telephone No. <br /> Emergency Telephone No. <br /> � <br /> Contractor Licence No. <br /> C Applicants Name (Print) H _ �� A*ATitle Date-244AICV 7/ <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 /> Nof Chemical Toilets Stored _ <br /> 3. 44 PERCOLATION TE6*6 <br /> — <br /> R.S. or R.C.E. Name 7` R.S.or R.C.E.No. <br /> Test Location Test Date/Time AAWi <br /> 4. ❑ SANITATION PERMIT,,. <br /> Job Address/Location <br /> Owner `E 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, 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 ththe work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r les d regul ns of oaquin Local ealth District. <br /> APPLICANT'S SIGNATURE X rq <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ianyW 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING <br /> DATE DATE E REMITTED <br /> AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS f <br /> PENALTY ; r' <br /> OTHER g a <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />