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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) S TAGS <br /> ~ ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is ere y made to car on business in the jurisdictional area of the Son Joa uln Local Health District <br /> rn Business Name (DBA) ��M X Address, <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. ^' Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) T Title ® Date 1Z_J <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 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License 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�t,_ocan Test Date/Time <br /> 4. L�SANITATION PERMIT }� <br /> Job Address/Location- , �T _!0.-7—&A,) <br /> Owne C. Jla Address�, f 1��c.'l.tJC�"T � 22-'S'EPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> to 'PERMANENT ❑ TEMPORARY ❑ NEW 2 rtEPAIR ❑ 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 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 certify that I ha a prepared thi application d that he w will be done in accordance with San Joaquin County <br /> ordinances, state law les and r lations, lf San quin o al Health District. <br /> APPLICANT'S SIGNATURE Aa <br /> G <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received 8y January 31 ❑ July 1 &Received By July 31 , <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED _ <br /> AMOUNT <br /> FEE <br /> LESS I' <br /> PRORATION Y <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a Sco4I <br /> Received by Date Receipt No. Permit No. Issu nce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />