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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 PERMIT S�P7AGE <br /> LIQUID WASTE <br /> Application is hereb made to caron bu in s in the w isdictional area oft San Joaquin L ai al h District <br /> rn Business Name (DBA) Add res <br /> z Owner �-- Address <br /> a <br /> M Firm Partners, Addresses a d elephone Number <br /> i-Business Telephone No. �- Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> Applicants Name (Print)` �- Title C 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 <br /> Description(Make/Yr., Color) I, <br /> Serial No. CAL. License No. CAL..Li=c ise Renewal No. <br /> Capacity—^-= Gal:,-Weights.&-Measures No-M..s..__. _ <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> I No. of Vehicles Storedd <br /> No:of Chemical Toilets Stored mm _ <br /> 3. ❑ PERCOLATION TEST " <br /> R.S. or R.G.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> f } <br /> 4. ❑ SANITATION PE <br /> Job Address/Location <br /> l Owner Addresses' ° <br /> SEPTIC TANK ❑ CESSPOOL FIELD ❑ SEEPAGE PIT- ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY E] NEW REPAIR ❑ OTHER <br /> 5. ,❑ CHEMICAL TOILETS For July 1, -June 30, 19 - <br /> Type Construction Disposal Site t <br /> No. Of Units Equipment Storage/Cleaning Location(s) <br /> 6. `❑ PACKAGE TREATMENT PLANT ;For July 1, -June 30,19 <br /> Operator Name 1 Where Certified <br /> f <br /> _Plant Location Y <br /> -Plant Capacity No. Units Served <br /> 7..-'[] LAUNDRY For.July 1r: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 /> - <br /> _ I hereby certi y t 1 have prepare this applica ' n a that the work-will be done in accordance with San Joaquin County <br /> W *� ordinances, stat la and ru es n re'u fi. ns the S Joaquin Local Health:District. <br /> �AP.PLICANT'S SIGNATURE a <br /> a.�..�-� <br /> ` h <br /> I ` FOR DEPARTMENT USE ONLY <br /> r Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH- ❑ January 1 &Received By January 31 ❑ July 1 d Received By July 31" <br /> BILLING REMITTANCE $ REMIT va <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> T '.DATE REMITTED <br /> pAE ` AMOUNT` <br /> E. FEE <br /> . F <br /> g LESS <br /> 5 PRORATION <br /> PLUS <br /> PENALTY <br /> F OTHER . <br /> OTHER <br /> Received by Date k1 Receipt No. � Permit No. - "Issuance p e Mailed Delivered <br /> I. APPLICANT-RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES `ice• 9 1681-E.HAZELLT _ E.,P.O.Box 2089 STOCKTON,.CA 95291 ; <br />