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Applications vrul tie Processes wnen buomlttea Properly t;ompletea. ue sure I o blgn 1 ne Application. <br /> APPLICATION <br /> (C"14on-Transferable, Revocable,and Suspendable SEPFAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to cTf on business in the jurisdictional area of the San Joaquin Local Fjeeallth�)Dissttrict <br /> Business Name (DI3A) Address s31 /_.-- l z 6(V - <br /> i Owner Address <br /> 7 Firm Partners, Addresses and Tele ho a Numbers C 0 I x <br /> iBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date O �' 3 — 7-Q'd <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 /> Job Address/Location ��J nf� <br /> Owner�L'��.\-.1If1-1�O - - Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW hTjREPAIR ❑ 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 CLE=ANING,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,an rule_ regulations of the San Joaquin Local 4alth District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: 13 ANNUALLY ❑ PER UNIT <br /> PER SITE ❑ EACH ❑ Janus 1 &Received By January 31 ❑ July 1 &Received.By July 31 <br /> ❑ January <br /> REMIT <br /> BASE EXPLANATION .BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOU <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS Y <br /> PENALTY <br /> OTHER <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 />