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Applications WIII 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 �f' <br /> LIQUID WASTE <br /> Applicatio e m deto car n b I ss in the jurisdictional area of the Sa l� uin LoT$Hea t District <br /> UF Business Na DBA) F1� ��C*'S �t��5_. '2 Address_— /� �" <br /> iOwner / /�' C��� exp Address <br /> aFirm Partners, Addresses and Tel Numt3ers — <br /> M Business Telephone No. �i�( [[�' Emergency Telephone No. __ <br /> Contractor Licence No. <br /> L Applicants Name (Print) 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. Lic-7.se 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 /> 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 Test Date/Time <br /> 4. ❑ SANITATION PERMIT n » <br /> Job Addree./Location $3�7 S C� /�/AfC,tzT Lip Ay <br /> O0rer `='Aey Qw<-,�S Address Sa-wt-e <br /> L`� SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW BIREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 _ <br /> Type Construction Disposal Site 12 u' <br /> No. of Units Equipment Storage/Cleaning Location(s) SAO- <br /> 6. <br /> ly 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 hat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, les and regulations of the S Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X �, ���� <br /> � \3 <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 E <br /> BASE EXPLANATION DATE DATE AMOUNT DUE CHECKED <br /> REMITTED <br /> AMOUNT <br /> FEE �S� I C �0 <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> hD <br /> Received by Dille Receipt No. Permit No. Iss n�AVF <br /> Mail Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.H ., .O.Pox 2009 STOCKTON,CA 95201 <br />