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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 Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT ��\ =�— h <br /> LIQUID WASTE �1" 9` _1 r c' <br /> Application is hereby made to carry on business in the jurisdiction rea of the San Joaquin Local Health District <br /> „Business Name (DBA) dress <br /> = Owner T:1JC _ Address <br /> Firm Partners, Addresses and Telephone Numbers ';^' <br /> aBusiness Telephone No. _ - _ __ Emergency Telephone No. <br /> Contractor Licence No. <br /> t Applicants Name (Print) y",4•.`=1iLF, c _ Title Date 4LIZI —��► <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r I : V <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 _ - _ i FF}-L L^iv<' c a L_ <br /> No. of Vehicles Stored <br /> No of Chemical Toilets Stored <br /> 3. 19 PERCOLATION TESTS �?'•�+',r\�'(;'S.1'Y F�l�-t L-" - ^ _ � ' L. =��I•=�� <br /> r R.C.E. Name `_ - �� +1_ I`•-1u:- F_0_�R.C.E. No. ==t— <br /> Test Location Test Date/Time �• - r` F "tr" `��'�' <br /> 4. ❑ SANITATION PEA1911T } •� 'y - _ _. <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 <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. Q 1 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I 1 <br /> t <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. <br /> APPLICANT'S SIGNATURE X / �' .� '� Title DateL— <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 16 Received By January 31 ❑ July 1 6 Received By July 31 <br /> REMIT <br /> E_BASE EXPLANATION BILLING REMITTANCE f AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE M 67 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> —, 76 — — <br /> Rece've'd byDat— e� 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 9520 <br /> 1 . _ <br />