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Applications Will Be Prc ed When Submitted Properly Completed. Be SI o Sign The Application. ��C <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby a e to carry on business in t e jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Mme, Address _�•A•_c3i _ a�7 <br /> Owner Address 12 - -- Address._ _ (y e►" --- <br /> L) Firm Partners, Addresses and Te phone NumbersCL AAi - <br /> Business Telephone No. -Ll1l -._.__-_ -._ _ Emergency Telephone No.62o �__3� --_dl1V <br /> j Contractor Licence No. <br /> a Applicants Name (Print) VA Title _JRA_ __ __ _ Date <br /> Please <br /> -- <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 _ -- <br /> No. of mica) Toilets Stored <br /> 3 PERCOLATION TEST D a/S- <br /> A.S. <br /> or R.C.E. Name _ _ R.S. or R.C.E. No. <br /> Test Location Ad.O• ,`.1 P__- Test Date/Time--3-:�-f - <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location - <br /> Owner _ —_--___ Address_ -- -- --- -- --- - <br /> ❑ SEPTIC TANK ❑ CESSPOOL [a 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 /> Plant Capacity _ __—_ No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -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 /> I hereby certify that I have pr are applicati and a work will be done in accordance with San Joaquin County <br /> ordinances, state laws. <br /> APPLICANT'S SIGNATURE X __ ___ itle ?G Date�Gr FOvj <br /> R DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 b Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED //AMOUNT_ <br /> FEELESS <br /> PRORATION Z- .Q� `4�l \ � rJ 1 o ------ <br /> PLUS <br /> PENALTY _— <br /> OTHER <br /> OTHER <br /> Re.c by Date RecejOt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 200 STOCKTON,CA 95201 <br />