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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> /1 1 (For Non-Transferable, Revocable, and Suspendable) SE?Trac` <br /> EN IRONMENTAL HEALTH PERMIT <br /> r.,)LIQUID WASTE <br /> Ir. Applica ion is hereby made to car �n usl ss In t"jurisdictional area of the San Joaquin Cal Health Distr* t <br /> OF Busines Name (DBA) a LT JA (7)r <br /> Address q L <br /> i Owner P._F �(��'� K(�L L Address <br /> Firm Partners, Addresses an Telephone Numbers <br /> ILBusiness Telephone No. 51 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) ( 'E S_ V6-si(\L.X Title Date <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 Gat.,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. ❑ PERCOLATION TEST <br /> R.S.'or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location 4 Testpate/Time 10 <br /> 4. 11 SANITATION PERMIT 0 JPd �"' S O E- P'trs� <br /> Job Address/Location S \tJ i W r4 L cy C[ <br /> Owner S = Address--- 6(N 9�- <br /> ` SEPTIC TANK ❑ CESSPOOL � EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 PERMANENT ❑ TEMPORARY ;NEW ❑ REPALR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site - V <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 herebyrt� have prepay this applicatigin and that the work will bed a in accordance with San Joaquin County <br /> ordinances, a law4, d rules and re ati ns he San aq in Local Heal District. <br /> APPLICANT'S SIGNATURE <br /> c ' <br /> �, tl <br /> j <br /> FOR DEP T USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION B NG REMITTANCE $ AMOUNT DUE CHECKED <br /> TE DATE REMITTED AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION - -— <br /> PLUS <br /> PENALTY - - --- <br /> OTHER <br /> OTHER <br /> Received by to Receipt No. Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Boa 2009 STOCKTON.CA 95201 <br />