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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 4 <br /> APPLICATION <br /> -- Non-Transferable, Revocable, and Suspendab t A <br /> ENVIRONMENTAL HEALTH PERMIT / EPTAGE' <br /> LIQUID WASTE <br /> Application is h reb ma a to carry onpbusiness in the jurisdictional area of the SLin Local Health District <br /> mBusiness Name (DBA) � ` •`- Address ! �a,{n�oaq` L <br /> aOwner /"�l-�2 Address <br /> 2 Firm Partners, Addresses and TelephoneNumbers _ - <br /> i Business Telephone No. Emergency;Emergency'Telephone No. <br /> h 7�i—h Ss. <br /> Contractor Licence No. r <br /> L Applicants Name (Print) �� ] / Title iLs lh�-I'v- Date y -�l <br /> Please check Applicable Category (1-7)and FIII 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 Chemical Toilets Stored . <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name - R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT -iL - < <br /> Job Address/Location _ 7' <br /> Owner - Address <br /> �"OPTIC TANK 11 ❑ CESSPOOL EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW _1:1 REPAIR ❑ OTHER <br /> S. ❑ 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 a <br /> Operator Name Where Certified -t>-- <br /> Plant Location - <br /> Plant Capacity No. Units Served <br /> 7. 11LAUNDRY. For July 1,-June 30, 19 <br /> SIZE: 13Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 0'DRY CLEANING, Chemicals Used/Amount/Mo. �~ <br /> �fl <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, and rules and regul tions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY/Y1/ - `^ <br /> 'aW l <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH ❑ January 1 Receivetl By January 31 ❑ July 1 S Received By July 31 (� <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE b AMOUNT DUE CHECKED <br /> DATE I N DATE REMITTED AMOUNT jx <br /> C <br /> FEE f (L <br /> LESS <br /> PRORATION M <br /> r <br /> 4 <br /> PLUS <br /> PENALTY / <br /> +OTHER <br /> OTHER ry <br /> Received by Date Receipt No. Permit No. suanc Date Mailed elivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />