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Applications WIII 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 <br /> LIQUID WASTE ' <br /> Application hereby toGt�IO to carry o business in the jurisdictional area of the San Joaquin Local Health District <br /> ,F-Business Name (DBA)� �.�1 Address—� <br /> z Owner < __ _ Address d �2� <br /> 4 � � <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No.!cam t.G <br /> L Applicants Name (Print) Title G�i � Date <br /> Please check Applicable Category (1.7) aid pill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMtT REGISTRATION (FOR EACH VEHICLE) �h <br /> For July 1, June 30, 19 _ _ _ Disposal Sites {}' <br /> Description(Make/Yr., Color) <br /> Serial No. ___CAL. License No. CAL. License Renewai No. <br /> Capacity Gal., Weights & Measures No, AO <br /> Equipment Parking Address Ul1 <br /> 2. ❑ PUMPER YARD l <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. i <br /> Test Location _._ Test Date/Time <br /> 4. USANITATION PERMIITt 8p <br /> Job Address/Location�.. 1'60 L a,,,,,,,ems- 7"r <br /> Ow w n �/f r I�a __.._ Address �6 S Corro <br /> SEPTIC TANK ❑ CESSPooL LEACHING FIELD 13 SEEPAGE PIT C1 PACKAGE PLANT l <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑. REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -Junq 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: <br /> 0, 19._—_.SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq'. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> 4 ordinances, state laws, and rules$nd regu to of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <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 July 31 <br /> REMIT <br /> 8ILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �J <br /> 1 AMOUNT <br /> FEE <br /> LESS <br /> PRORATION y •r$ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dale Receipt No. Permit No. I sua a Date Mailed Delivered <br /> . 1 <br /> t APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />