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APPLICATION v <br /> (Tor Non-Transferable, Revocable, and Suspendabley-� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SL?TAGE <br /> LIQUID WASTE <br /> Application is hereby-( agp to car ryoni business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) M <br /> Address- d aa`,( r_ u 1 ZY/7 *4 1/�� -� <br /> z Owner Address Trl� A <br /> irm Partners, Addresses and Telephone Numbers <br /> °aQmBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> ` applicants Name (Print) —Titlecji� Date <br /> lease check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 'or 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 /> quipment Parking Address <br /> —2. ❑ PUMPER YARD ' <br /> For July 1, June 30, 19 <br /> Vo. of Vehicles Stored <br /> `Vo.of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST O <br /> 4.S. or R.C.E.Name R.S.or R.C.E.No. <br /> I <br /> rest Location Test Date/Time <br /> -14. ❑ SANITATION PERMIT <br /> Job Address/Location ��� ._—Pr A <br /> C' <br /> Dwner _ �I✓p g ��r Ad` ess <br /> ..� SEPTIC TANK Elrr--,,CESSPOOL �r.� LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE P'-'7'-- <br /> 1-1 <br /> T <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site l ' <br /> �No. of Units Equipment Storage/Cleaning Location(s) _ W <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 L <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 and regulations toe 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 /> BILLING REMITTANCE $ REMIT <br /> am BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> rill <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS I <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 24 G <br /> Received by Date Receipt No. Tlermit.No. I uance ate Mailed De d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />