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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 PERMITSEP-AGE <br /> LIQUID WASTE L <br /> Application i reby made to carryon sine In th u�r dl�tional area of the S_ Joaquin Local Healt istrict� <br /> OF Business N (OBA) lvtxf�_A_ � C't� Jdressz Owner _ Address <br /> Firm Partners,Addresses an <br /> Telephone Numbers <br /> aBusiness Telephone Emergency Telephone No. <br /> Contractor Licence No. 32-9 Z_Z _ _ -----.-.-- J_ <br /> L Applicants Name.(Print) _� F-'e ._ Title v Date <br /> a v" <br /> Please check Applicable Category (1-7) and Fill in the Required Inlormatlon <br /> .. 1. ❑ PUMPER VEHICLE PERMIT-REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 � _ Disposal Sites <br /> Oescription{lvlake/Yr.;Color) <br /> Serial No. CAL. License No. _. CAL. Liccese Reacwal No. <br /> Capacity __ __ __ Gal..Weights-& Measures-No.- <br /> .... <br /> rt aEquipr nt Parking Address <br /> j 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 Q.E. Name _ R.S. or R.C.E. No. — _- <br /> Test L ation .----_ ._......_. Test Date/Time - <br /> 4. SANITATION PERMITj <br /> Job Add <br /> re /L ation '�'ro <br /> 01 <br /> O.,wper– ddb s_57sno i� <br /> T SEPTIC TANK ❑ CESSPOOL ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT O <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER r <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 1 <br /> Type Co-istruction _ _ Disposal Site <br /> No of Units _ _ Equipment Storage/Cleaning Location(s)- <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name ' – -- Where Certified <br /> Plant Location _ !{ <br /> Plant Caoacity '� No. Units Served ///'''���� <br /> 7. LAUNDRY For July 1, -June 30, 19 ___ `� <br /> SIZE: El Less Than 1,000 Sq. Ft./ El More Than 1,000 Sq. Ft. f C <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - – <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,and rules and reg lio s of the San Joaquin Local Health District. <br /> Lr,APPLICANT'S SIGNATURE X --- L -- <br /> e <br /> ( FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNI I ❑ PFR!-,ITE ❑ EACH ❑ January 1&Recceived By January?t ❑ July 1 &neceived By July 31 �. <br /> RFMIT- <br /> BASE EXPLANATION BII l IT <br /> REMITTANCE $ <br /> AMOUN DUE CHECKED <br /> DATE DATE REMITTEC AMOUNT _ A) <br /> FEE r <br /> LESS ` <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I OTHERi <br /> ' Rrceivrd by Date Receipt No. ermil No Is uance to Mailed Dehwp d <br /> APPLICANT—RETURN ALL COPES TO: ENVIRONMENTAL HEALTH PERMIT!SERVICES 1601 E.HAZELTON AVE.,P.O.Soe 2009 STOCKTON,CA 95201 _ <br /> eme aL kW -VG t$_7it�.IZ <br />