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Applications Will Be Pro- "sed When Submitted Properly Completed. Be Si To Sign The Application. <br /> 1410W APPLICATION Z ? c. <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 /> 3usiness Name (DBA)_ _ _ _ ____ Address ---- <br /> )wner ��'__ P �JJr� �� Address 2Vw- -- <br /> Irm Partners, Addresses and Telephone Numbers -- - <br /> 3usiness Telephone No. -- - -- - - <br /> Emergency Telephone No.-- -- ---- <br /> ;ontractor Licence No. <br /> >pphcants Name (Print) y� OSr� /� _ Title �l V� �Er - Date - <br /> Nease check Applicable Category (1-7) and Fill in the Required Information <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Disposal Sites _ <br /> :or July 1, June 30, 19 -_ - <br /> Description(Make/Yr.. Color) - <br /> 3erial No. __ _ — CAL. License No. CAL License Renewal No. -_-- <br /> �',apacity 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. ;A PERCOLATION TEST _ - <br /> R.Swer R.C.E- Name 'lam------- !fir ReC_E2No. -- <br /> Test Location a 60 Test Date/Time St f_� - - <br /> 4. ❑ SANITATION PERMITp <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 —_ --- - - -No of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> Where Certified --- <br /> Operator Name - -- -- <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. r <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - - - -- �I <br /> _76t � � <br /> �Q I hereby certify that I have prepared this applicati nand that the work will be done in accordance with San Joaquin ounty <br /> ordinances, state laws _ <br /> Title <br /> FOR <br /> Date <br /> APPLICANT'S SIGNATURE X - ��r�'— --- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> I EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE ^ <br /> DATE DATE REMITTED AMOUNT <br /> 1 q ( <br /> 1-1 <br /> FEE .� . G' - A/, _s <br /> LESS r <br /> PRORATION —_ _ ----- J"-'� <br /> PLUS — — <br /> PENALTY <br /> OTHER _ u <br /> OTHER (/� <br /> _ _ ____ `� °�? G - —/ Issuance Date Mailed Deiivere7 <br /> ecerved by Date <br /> Receipt No Permit No <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES C. <br /> 1601 E.HAZELTON AVE..P.O.Boa 2009 STOCKTON. <br /> I <br />