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r TheAppliCallOrl. <br /> Applications Will Be Processed When Submitted Properly Completed. BeSureTo Sign <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) S) pTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> "y LIQUID WASTE_ <br /> Application is hereby made to carry on business in the jurisdictional area of the San jloaquin Local Health Districts <br /> ,n Business Name (OBA) Address G� <br /> c5 � <br /> z Owner Address – <br /> a <br /> Firm Partners, Addresses and Telephone Nu bers <br /> i a Business Telephone No, Emergency Telephone No. <br />! -j Contractor Licence No. <br /> /�o1h tic �. Date 7 ID Applicants Name Name (Print) Title 1 <br /> Please check Applicable Category (1-7)and Fill in the Required Information {f <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) --�. <br /> For July 1, June 30, 19 ) Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity 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. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br />{ R.S. or R.C.E. Name Ul <br /> f Test Location Test Date/Time <br /> EI v <br /> 4. ❑ SANITATION PERMIT WE <br /> U� <br /> j Job Address/Location 54 U <br /> Owner AM—.-C Address <br /> l SEPTIC TANK El CESSPOOL EACHING FIELD 11 ❑ OTHER <br /> SEEPAGE PIT ❑ PACKAGE PLANT ' <br /> P Pe ERMANENT ❑ TEMPORARY *NEW El REPAIR <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 /> t 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> P Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 /> � T <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 regulati ns of the San Joaquin Local Health District. <br /> r <br /> I APPLICANT'S SIGNATURE X <br /> 0 42 <br /> OR DEPARTMENT USE ONLY <br /> !` Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE C1EACH ❑ January 1 &Received.By January 31 ❑ July 1 &Received REMIT <br /> July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHFCKFD <br /> y -- DATE DATE REMITTED AMOUNT <br /> Oq <br /> FEE 4 <br /> LESS <br /> i PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> pat Receipt NO. Permit No. Issuance Date Mailed Delivered <br /> Received by <br /> APPLICANT ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ' 7601 E.HA2ELTON AVE.,EP.O.Box 2004 STOCKTON,CA <br /> - �. <br />