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16LC " �r Appllcatlonl Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ///��� APPLICATION <br /> �I- f (For Non-Transferable, Revocable, and Suspendable) <br /> f6(// ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> v,Business Name (D A) A}Qdress <br /> i Owner Address�SSz` �" Gy /p'.�/7 .�•0/7e / <br /> i <br /> Firm Partners, Addresses and Telephone Numbers - <br /> 9'� Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. _ <br /> L <br /> L A <br /> PPllcants Name (Print - <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 G•/� <br /> No.of Chemical Toilets Stored _ <br /> 3. PERCOLATION TEST <br /> Fl f.er R.C.E. N,aTme O// C � R gr R.C.E. No. <br /> rest Location 4/ `�/% '� 6 z-�'" Test Date/Time S'/Z <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ 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 /> PlantCapacity No. Units Served -- <br /> 7. 11 LAUNDRY For July 1, -June 30, 19 <br /> SIZE: 13 Less Than 1,000 Sq. Ft., 13 More Than 1,000 Sq. Ft. L` " <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> t hereby certify that I have prepared this application and that the work will be done in actor ante with In Joaquin County <br /> Av <br /> ordinances, state laws. <br /> APPLICANT'S SIGNATURE c-- TitleZZI-1/ �� Date S <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 A Recaived By JAnWry 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT_ <br /> FEE 7 �O Q/ / 17/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER — <br /> OTHER <br /> eiv6d by bate Receipt No /Permlt No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 21109 STOCKTON.CA 9SM1 <br />