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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 /> g}_,Pj , . <br /> ENVIRONMENTAL HEALTH PERMIT , <br /> LIQUID WASTE <br /> Application is 2reby made to arry o busi sin thejuri Ictional area of the Sa�o`aqulnn cal Health District <br /> �;Business Nam .DBA) _ �r�1J -Addressl� <br /> i Owner r 1 _ - Address - -- <br /> Firm Partners,Addresses and Telephone-Numbers ---- - <br /> aBusiness Telephone No._��e �fG'�- —.___._. Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants Name(Print) ��f-E- Title ----��� — Date <br /> Please check Applicable Category (1-7)and Fill in the Required Ififormation <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 QJ <br /> 1W 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 L�tion Test Date/Time <br /> 4. Rr SANITATION PERMIT <br /> Job Address/Location <br /> 21 <br /> Owner Address'��_ C LJ <br /> C3 SEP TIC TANK ❑ CESSPOOL ❑ LEA HING FIELD rr-;,,� PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW tsd' PAIR ❑ 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) 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,and rules a gulations of the San Joaquin 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 /> BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS ten/ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. ermit No. Iss ante Date Mailed eli ere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />