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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign a pp L it <br /> _ APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) �� ': � EPTAGE 11110ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby mad car on bus' ss in he ju%jAa&r�Nt Districtvie <br /> tjos rnBusiness Name (DBA) c v <br /> Address <br /> a Owner <br /> J Firm Partners, Addresses and Telehone Nu hers •r <br /> a Business Telephone Nolategory <br /> Emergency Telephone No. <br /> a <br /> ile <br /> 1 Contractor Licence No. ss Q, pate <br /> Title <br /> LApplicants Name (Print <br /> Please check Applicabl (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 3 <br /> Description(Make/Yr., Color) CAL. Liccnse Renc,wal 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 <br /> No. of Vehicles Stored r <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.No. #. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Locn Q� <br /> 4. VSANITATION PERMI <br /> Job Address/Location <br /> Owner Address <br /> ❑ LEACHING FIELD ❑ SEEPAGE PIT PACKAGE P ANT <br /> EPTIC TANK ❑ CESSPOOL C3 REPAIR OTHER' <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW <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 /> . a <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 /> k <br /> I 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, , rules and r laf y of an J�a cal Health District. <br /> f APPLICANT'S SIGNATURE X <br /> I a <br /> �Ip FOR DEPARTMENT USE ONLY r <br /> ! Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Rece-v d By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUN DUE CHECKED <br /> I BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE LIS �V-5 <br /> LESS <br /> k PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7 M <br /> ate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> Received by 1601 E:HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> �� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - r <br />