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Applications Will Be Processed When Submitted Properly UOMP[etea.oc aule I W al!.- -wv---- <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) $ TAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appiication is eret)y made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> r„ousiness Name(DBA) Address <br /> a Owner __ 1�Telep�hone <br /> Address <br /> u hrrn Partners,Addresses ambers <br /> a Business Telephone No.—V�~ "�� '"�� Emergency Telephone No. <br /> Contractor Licence No. -'-� e5 ';2 <br /> - - <br /> LApplicants Name (Print).. (,� 1�� �� � Title �� =1�a 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.'- _ e _CAL.License Renewal No. <br /> �--�_ <br /> Capacity Gal.,Weights&Measures No. - <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 a <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 /> T\ <br /> Test Location Test Date[Tirrie <br /> 4. ❑ SANITATION PERMIT f /V 5 5 <br /> Job Add rens/Location r . ,�a } •�f 1c - I�-t- A G Q <br /> Owner Address <br /> POIS'EPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> IZZ <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHER' <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> 'ype Construction Disposal Site <br /> .Jo.of Units Equipment Storage/Cleaning Location(s), <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> - Where Certified <br /> Operator Name <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. w <br /> I hereby certify that l have prepare.d-this-application and-that the work will be done'in accordance with San Joaquin County <br /> ordinances,state laws,and rules and reg ations f the 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 9 Received By January 31 ❑ July 1 8 ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE § AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY '- i <br /> . . <br /> .*— OTHER' <br /> OTHER <br /> Y <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> 16D7 E.HAZELTON AVE,P.O.BOX 2009 STOCKTON,CA 93201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />