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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 /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) Address <br /> z Owner Address '75-.3ZO <br /> Firm Partners, Addresses and Telephone Numbers <br /> f3 - S D 8 313-12 <br /> aBusiness Telephone No. (10q) 5ag; I'S/S' Emergency Telephone No. <br /> Contractor Licence No. /� <br /> L Applicants Name (Print) n �'� Title IQW 666& Date p21.26 % <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 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 /> Nk c Chemical Toilets Stored <br /> 3. NZ,.IPERCOLATION FEST ro ,f s <br /> R.8. or .C.E. Name .J 2 W r\ R.S. or R.C.E. No. <br /> Test Location Q O I� Dr7 Time <br /> 4. ❑ SANITATIONPER7,T J) ''QQ e1 CC•lt^ ��i <br /> Job Address/Location h �� Y\� ' V�/Si C 1t✓O X J �c�f t � <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ 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) <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 ork will be done in accordance with San Joaquin County <br /> ordinances, state laws, rules and reg i s:"n Local Health District. <br /> APPLICANT'S SIGNATURE X -0 r <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 $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE -5 <br /> LESS <br /> PRORATION <br /> PLUS S( V111 Y, <br /> PENALTY V <br /> OTHER n �jJ r <br /> OTHERrO►� 'Gv U <br /> Received-by— Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />