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Applications Will Be F .e ssed When Submitted Properly Completed. Be a To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA) _ Address-------_____ <br /> Owner -_ S.s�— LO/S �xo2ast _QQAddress 5 `��/erg T /C_D_. _ / Q <br /> J Firm Partners. Addresses and Telephone Numbers l =O T <br /> CL Business Telephone No �Ll__3¢ _ ___ ,-_ Emergency Telephone No. <br /> Contractor Licence No. <br /> `Applicants Name (Print) ,d! tTitle ;� _pa_ <br /> /r te <br /> 2r <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 hemical Toilets Stored <br /> 3. ERCOLATION TqS i <br /> A.S. or R.C.E. NameGs. _ R.S. or R.C.E. No. <br /> Test Location - �,.-t�_� > LLQ— - 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, 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 that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws / 47 <br /> ?-'/ <br /> APPLICANT'S SIGNATURE X _ Title �� —-- Date--- -4 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January T1 d Received By January 31 ❑ Juiy 1 d Received By July 31 <br /> -- REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AAL40UNTT(_ <br /> FEE <br /> LESS ` G = O 4 C -- <br /> PRORATION r <br /> PLUS <br /> PENALTY --- <br /> OTHER <br /> OTHER <br /> RecewRecei —ed 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 />