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Applications Will Be ' -?ssed When Submitted Properly Completed. Bf 'e To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> 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 /> HBusiness Name (DBA) Address ---- - <br /> / �' <br /> - - <br /> ~ f��or�c- ✓"✓7Q�;i:' Address P�>,.:� . , , %-rs�+�• - <br /> a Owner - - - - - -- - <br /> uFirm Partners, Addresses and Telephone NumbersIL <br /> a. - - -- ---- - -- -- <br /> Business Telephone No. -- _ - _ _ Emergency Telephone No. <br /> � Contractor Licence No. -- <br /> e Applicants Name (Print) -- - -_- Title ---- ---- Date - <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 StoredNo. of Chemical Toilets Stored ----- - ------- --- <br /> 3. 11 PERCOLATION TEST <br /> RR.S-en R.C.E. No <br /> .S-,Dr R.C.E. Name -- ------------ -- -�•- <br /> Test Location ! Test Date/Time ____- --- --- ------- ---- --- — <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location ` <br /> Owner -- <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 /> Plant Capacity _ No. Units Served 3 <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. T <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. --- — ------- - <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. <br /> APPLICANT'S SIGNATURE X ------ .--- ---- --- — Title Date --- -- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 Ik Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> GATE GATE REMITTED AMOUNT <br /> FEE / /L X, <br /> LESS <br /> PRORATION <br /> PLUS _ <br /> PENALTY <br /> OTHER --- <br /> OTHER <br /> Received by at Receipt No Permit No Issuance Date Mailed Delivered <br /> (CANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2006 STOCKTON.CA 95201 <br />