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Applications Will Be Processed When Submitted Properly Completed. tie bure Iu � I <br /> APPLICATION , <br /> _ @ <br /> (For Non-Transferable, Revocable, and Suspends e) $EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby, de to car on usines,*)n the jurisdictionaAddresss area of the San Joaquin Local Health District <br /> i Stlh B <br /> y Business Name (DBA} Ad ress _ <br /> a Owner <br /> Y Firm Partners. Addresses and Telephone�Numbers <br /> /Q Emergency Telephone No. <br /> a Business Telephone No. <br /> a <br /> Contractor Licence No. Title Y Date <br /> L Applicants Name (Print) <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 For <br /> Sites <br /> Description(Make/Yr., Color) ( CAL. Licznse 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 Q <br /> No. of Vehicles Stored V <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. {� <br /> R.S. or R.C.E. Name o <br /> " Test Date/Time <br /> p Test ocation Y n <br /> + [ <br /> T 4. SANITATION PERMIT <br /> Job Address/Lo ation *,``k ..' 4+Address <br /> Owner ❑ PACKAGE PLANT <br /> l - SEPTIC TANK ❑ CESSPOOL LEA H1NG FIELD ❑ SEEPAGE PIT ❑ OTHER f <br /> ❑ TEMPORARY ❑{NEVti— REPAIR <br /> PERMANENT ,. <br /> 5. ❑ CHEMICAL TOILETS Forbuly 1, -'une'3l], 19,; { <br /> Type Construction <br /> _:_r �,,.� "" '"DISpOsal Site _ <br /> No. of Units a(r- -.Equiprtlent,Storage/Clean ing Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified - - <br /> f Operator Name <br /> ` Plant Location ) <br /> .1 �No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <br /> I hereby certify that I have prepared this application and that the vor will be done in accordance with San Joaquin County <br /> ordinances, state laws, a and regu-at of a San Joaquin I Heal District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> k 'Fee IS DO@' ❑ ANNUALLY ❑ PER UNIT [LFPER SITE ❑ EACH ❑ January 1 &.Received By January 31 ❑ Juiy 1 &Received By Juky 31 <br /> REMIT <br /> s" BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 1 "s' BASE - EXPLANATIONPATE DATE REMITTED AMOUNT <br /> FEE <br /> [[ LESScl <br /> PRORATION � •� <br /> PLUS .– <br /> PENALTY • 1' �n <br /> ' OTHER <br /> OTHER <br /> )� ( y �9— Issudnce Date Mei4ed Deiivered - <br /> Received <br /> Vat Receipt No- Permit No. <br /> APPLICANT—RETURN ALL COPIES-TO:- ENVIRONMENTAL HEALTH PERMITISERViCES 1601 EHAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 <br />