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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> �* ENVIRONMENTAL HEALTH PERMIT ShPTAGE <br /> } LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the S9j;Joagw oval He Ith District <br /> �;Business Name (DBA) Address Y ��Q� �� <br /> z Owner Address U <br /> X <br /> Firm Partners, Addresses and Tel p one tium�bers <br /> 4!14 Emergency <br /> j�� " r <br /> a Business Telephone No. �-� `- 1-4one <br /> Telephone No. <br /> a <br /> � <br /> Contractor Licence No. <br /> LApplicants Name (Print) �� Title rJA� 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 CIA <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse 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 . n Test Date/Time <br /> 4. EPSANITATION PERMIT / <br /> Job Address/Location <br /> Own Address�� �^ — <br /> IC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEE,PAGE PIT ❑ PACKAGE PLANT <br /> 1 PERMANENT ❑ TEMPORARY ❑ NEWR'EEPAIR ❑ OTHER <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 /> 6. ❑ PACKAGE TREATMENT PLANT For July.1, -June 30, 19 <br /> Operator Name r` _ - 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 /> s <br /> r <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 regulations ofthe Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE G <br /> FOR DEPARTMENT USE O LY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH © Jan ar Recei ed By Ja ary ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTA C $ AMOUNT DUE CHECKED <br /> DATE D REMIT <br /> IT AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. JF Issuancb Date Mailed Delivered T -7 l y Q <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,/CA 85201 <br /> Y <br />