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APPLICATION <br /> r Non-Transferable, Revocable,and Suspendabf <br /> ENVIRONMENTAL HEALTH PERMIT S�PTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San oaquin Local Health Dist/rlI;t <br /> OF Business Name (DBA) Address <br /> aOwner - ct Address <br /> Firm Partners, Addresses and Telephone N <br /> CL <br /> Business Telephone No. � 3 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) C C �C�j[e Title r0�-� �� Date <br /> Please check Applicable Category (1-7) and Fill in the quired 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 PERMITZF <br /> Job A/djress/Location 3 c ��' <br /> Owner �A 1-�� L t l�2iG Address . �& 11e_ <br /> EPTIC TANK ❑ CESSPOOL . gL-L15ACHING FIELD ❑,SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR' ❑ OTHER n .' <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site ry <br /> No. of UnitsI Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified m <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 a plication and that the work will be done in accordance �Joaq in C unty <br /> ordinances, state laws, and rules and re tions f the San 0 quin 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 /> REMIT <br /> SASE EXPLANATION <br /> BILLING REMITTANCE $ <br /> DATE PATE REMITTED AMOUNT DUE CHECKED <br /> r- AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> eceived by Date Rece#pt No Permit No, iss ante a e Mailed _ Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952DI <br />