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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. o7,<p67 <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) Swl'TAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica ion is hereby a e to car o business i e jurisdi tonal area of the- n JaaQuin ocall Health istrict �� <br /> F Business Name (DBA) 1-- 19ddress—� - <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses anq T ho�Nurl;�ber <br /> aBusiness Telephone No. 1a Emergency Telephone No, <br /> Contractor Licence No. <br /> L Applicants Name(Print) Title ate <br /> Please check Applicable Category (1-7)and Fill in the Required Information oaba' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Y <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) .�- <br /> Serial No. CAL. License No. CAL. License Renewal No. Q <br /> Capacity -- Gal., Weights &Measures No. r <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 Location Test Date/Time <br /> 4. ❑ SANITATION PERtT!5 <br /> Job Address/ cation <br /> O ner <br /> Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR 11 OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 (n <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 T' <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 /> I hereby certif tha have prepared th' applicati and that the work will be done in accordance with San Joaquin County <br /> ordinances, ate�Iawsruleand re ul io oft a Sa oa n Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 d Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> A SDATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS / <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt 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 />