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pppcanonswill tsevrgcesieltwhen SubmittedProperlyCompleted. BeSure To Sign The Application. <br /> - <br /> APPLICATION- <br /> (For Non-Transferable, Revocable, and Suspendable) 7 6 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> i LIQUID WASTE <br /> i Application iseby ade to ry on business in the jurisdictional area of the San Joaquin Local Health i trict <br /> Business Name {DBA) 17M 1_ Address 1 r <br /> " a Owner Address <br /> Firm Partners, Addresses and Telephone Numbers_ <br /> aBusiness Telephone No. T Emergency Telephone No. <br /> Contractor Licence No. 19 <br /> L Applicants Name (Prin Title Date <br /> Please check Applicab tegory (1-7) and Fill int the Flequired Information <br /> 1. ❑ PUMPER VEHfC PERMIT REGISTI7ATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites 1 <br /> Description(Make/Yr., Color). <br /> Serial No. _CAL. License No. CAL. License Renewal No. Gl <br /> Capacity Gal., VVelghts & Measures No. <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD <br /> r <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.O.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ASANITATION PERMIT V <br /> Job Address/Location, -��-�� _ __2 <br /> Owner �J�' ' , ��� � �- <br /> Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY C] NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19_ <br /> Type Construction <br /> r _- Dit}posal5ite <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> t 6_ ❑ PACKAGE TREATMENT PLANT For. July 1, - Aine 30, 19 <br /> Operator Name Where Certified fl <br /> Plant Location <br /> '• Plant Capacity No. Units Served <br /> r 7. ❑ LAUNDRY For July 1, -June 30, 19_ _- <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., Q More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEAN ING,.Chemicals Used/Amount/Mo. <br /> I hereby certify thaJhavp ared t I9 pplication an at the work will done in accordance with San Joaquin County <br /> ordinances, state laand tions € Joaquin Local alth District. <br /> I APPLICANT'S SIGNATURE X 67 <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> ,i Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PEn SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 1 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> AMOUNT DUE CHECKED <br /> DATE DATE REMITTED �/,J <br /> AMOUNT <br /> y FEE � �� <br /> LESS <br /> PRORATION <br /> ' PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipl 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 /> A <br />