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Applications Will Be Proc1 i When Submitted Properly Completed. Be Sur Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appllica�tion�is hereby made to carry on buslne,., In the jurisdictional) area of San Joaquin Co�upIty <br /> H Business Name (DBA) S �ll <br /> �+ r���rr F 1 1 '_ Address ZtL /N-(ip-�✓� -_ ! <br /> aOwner T�~ L C-C/11 - - Address ------ <br /> Y Firm Partners, Addresses and Telephone Numbers <br /> 5. Business Telephone No. (� --L L__--_--__ -_-_-___ Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants Name (Print) > r 11. _, -- - ---- __.___.___. Title G�1� Date (1 - ___ <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 ____ ( > CNo. of Vehicles Stored <br /> No. of Chemical Toilets Stored - <br /> 3. PERCOLATION TEST '"� <br /> R.S. or C�Name f'/ i7 ( F / R.S. or(�R_CgE.'No. 7, � -- <br /> Test Location <br /> 9!/a A _r.'Test Date/Time fir - Ott - - 13 <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. � - <br /> APPLICANT'S SIGNATURE X -- G14 Title A F'/i ; Date <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 /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE -- <br /> LESS <br /> PRORATION /Q/C <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Recered by Date Receipt No Perm.l No Issuance Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMIT/SERVICES 44, N. San Joaquin St. P.O.box 2000 STOCKTON,CA"201 <br />