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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application <br /> APPLICATION <br /> - <br /> (For Non-Transferable, Revocable,and Suspendable) SEP7AGE <br /> ' ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application Is hetebly made to carryon business in the jurisdictional area of the San Joaquin Local Heallb District c� <br /> P ] �x .��1� Address <br /> N Business Name (DBA) <br /> i Owner Address <br /> a <br /> I0 Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. �� Emergency Telephone No. <br /> -J Contractor Licence No. — <br /> LApplicants Name (Print) 77 //ffS Titled Date <br /> F Please check Applicable Category (1-7) and Fill in the Required Information d <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) J <br /> For July 1, June 30, 19 Disposal Sites <br /> j Description(Make/Yr., Calor) <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�Loca on Test Date/Time U <br /> SANITATION PERMIT \ <br /> Job Address-/Location <br /> Owner Afie. elp'1-0 ;I Address <br /> ❑ SEPTic TANK ❑ CESSPOOL LEACHING FIELD C-SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, June 30, 19 <br /> r <br /> f <br /> Disposal Site <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served { <br /> 7. ❑ LAUNDRY For July 1; =June 30, 19— <br /> SIZE: <br /> 0, 19SIZE: ❑ 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 h e prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, rules d regul ns of. e�San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> 74d A)0 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH - ❑ January 1 &Received By January 31 ❑ July 1 &Received By JuVy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION -. <br /> PLUS <br /> PENALTY <br /> OTHER r <br /> i <br /> i OTHER r <br /> Received by Date Receipt No. Permit No. Issuance bate Mailed Delivered <br /> 'APPLICANT—RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,-P:O.Box 2009 STOCKTON,CA 85201 <br />