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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 SEI'TAGE <br /> LIQUID WASTE <br /> A y lication is here made to car on business in the jurisdictional area of the Saa Joagul oval die lth District <br /> .,sines Name(DBA) �� Address Y <br /> aOwner a .�. C_ Address <br /> 3 Firm Partners,Addresses and T.e�irep one blum/�bers ,��1 �� � <br /> Business Telephone No. T�s o' `��-G Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) � ���G Title Date D <br /> Please check Applicable Category(1-7)and Fill In the Required Information --� <br /> 1. I] 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 15e 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,,Loc on Test Date/Time <br /> 4, t�3'SANITATION PERMIT <br /> Job Address/Location <br /> Own Address§rp <br /> 7lC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SE AGE PIT ❑ PACKAGE PLANT .. <br /> VPERMANENT . ❑ TEMPORARY ❑ NEW - EPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-'June 30,19 i <br /> •pe Construction Disposal Site <br /> .d. of Units Equipment Storage/Cleaning Location(s) -1 <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 /> J <br /> 1 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 regulations of the San Joaquin Local Health District. <br /> r­lw� k <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE O LY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ Jan ar Recei By Ja ry ❑July 1&Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTA C $ AMOUNT DUE CHECKED <br /> DATE D REM ITT AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 100 <br /> OTHER <br /> zhgh,Received try Date Receipt No, Permit No. tssuane Dete Mailed Delivered T r,1t� O <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.box 2009 STOCKTON,/CA 95201 <br />