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,• Applications Will Be Processed When Submitted Properly.Com <br /> pleted.'Be Sure To Sign The Application. <br /> APPLICATION a <br /> (For Non-Transferable, Revocable, and Suspendable) SEP <br /> ENVIRONMENTAL HEALTH PERMIT TAGE <br /> LIQUID WASTE— ti_ <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,F Business Name (DBA) r Address Di I. 6_z2 $f,� <br /> zz OwnerF Address �` `E'• , <br /> Firm Partners,Addresses and Telephone Numbers °` " " " i <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. "' :''s" t°• S. <br /> L Applicants Name (Print)_�Z� �a��4167i/z—__ � Title r .�,....,_ Date "Z6 <br /> Please check Applicable Category(1-7) and Fill in the Required Info ormation1 <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATION'(FOR EACH VEHICLE) <br /> For July 1, -.--June 30, 19 - Disposal Sites- .J <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity, Gal., Weights & Measures No. <br /> t Equipment Parking Address b <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. NameR.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location 47 y <br /> Owner 0 ® <br /> - Address <br /> I ❑-SEPTIC TAN ❑ CESSPOOL ® LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> I ❑ PERMANENT ❑ TEMPORARY ❑ NEW ® REPAIR 13 OTHER <br /> 5. El CHEMICAL TOILETS ForJuly 1, -June 31 199, +C <br /> Type Construction y f. `" Disposal Site'ti <br /> l No. of Units (m Equipment Storage/Cleaning Locations) ' <br /> F 6. ❑ PACKAGE TREATMENT 1i For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> i . <br /> Plant Capacity ='f No. Units Served <br /> l 7. ❑ LAUNDRY. Far,July 1, -June 30, 19 <br />' SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> E❑ DRY CLEANING, Chemicals Used/Amount/Mo.. <br /> I#E!T}g@l g f9F�l@�FFPt 6Q�gt=F jB>j?tyfl3�9f'.fi �iEt@#@Ifs€.�ir�?'rl�er#i#i� thfR nth§ 0►10f14111910work,orwhich WsArmitIsissi;od,Ishal!iorw,ployaMr�istsiiri"§uEfl�Ia[lller F1sla uge�nte§ul�esf'll?4�iPf��laP4s I I s I s rj y � <br /> Bn.rac#at s 1'fiil� of st h:rAl 1 FilIjF3 aii-"'r lfurg e�,ilitlps tin falIpwvnp, "I QuIlty-thot III iito perfoar ance of 1110 work which this permit is issued,t shall <br /> $fd r8 �4F§b §4I?1§� 1R yf�F !11�{}s cg{fl�ellk3liflit i Wr bl G�tlferniii:'' <br /> I hereby certify that I have prepared this application and that-the-worlC will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulationsofthe San Joaquin'Local Health District. F <br /> APPLICANT'S SIGNATURE X <br /> 'I - - .- ..� FOR DEPARTMENT USE ONLY _ <br /> Fee Is Due: ❑ ANNUALLY 11 PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> FF. BASE EXPLANATION BILLING REMITTANCE $ REMIT' <br /> ,f DATE DATE REMITTED AMOUNT DUE CHECKED T <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - - <br /> PLUS <br /> 'I <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by s 1 bate Heceipt No. I Permit No. Issluance D to ,.�Mailed' Delivered -.. <br /> APPLICANT�RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - - 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 9520T <br />