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Applications" Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> d APPLICATION <br /> �� I (For Non-Transferable, Rerocabie, and Suspendable) SEP AGE t <br /> 3f ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> e <br /> Application ishapeby made to carry ogbusiness in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Address <br /> Address <br /> z Owner e!, Address <br /> Firm Partners, Addresses and Tele ane Numbers - <br /> CL Business Telephone No. �4 77 Emergency Telephone No. <br /> Contractor Licence No. ! - <br /> 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) t <br /> -For July 1, ,4 June 30, 19 11— ""Disposal Sites _ ' <br /> Description(Make/Yr.,Color)7—Illt <br /> Serial No. y _CA_L. License Noy° CAL. License Renewal No. <br /> Capacity ISM' Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD i `_ <br /> For July 1, June 30, 191 `gyp <br /> No. of Vehicles Stored <br /> t <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ��' FY <br /> R.S. or R.C.E. Name R.S. or R.CiE.No. <br /> i1 IM ` Test Date/Time <br /> Test Location > - <br /> i <br /> 4. K SANITATION PERMIT �� <br /> Job Addres /Location vave' N4 d n. • <br /> Owner t ~T Address <br /> ` r.'` t❑ PACKAGE PLANT ! <br /> SEPTIC TANK ElCESSPOOL .LEACHINGdFIELD ❑ SEEPAGE PIT <br /> PERMANENT C] TEMPORARY NEW ❑ REPAIR;" tX OTHERS t�iCEyl�Et 611T3 sT <br /> r '5. ❑ CHEMICAL TOILETS,-For July 1,-June 3919 <br /> Type Construction SNI "�3► Isposal Site <br /> No. of Units ;kms Equipment Storage/Cleaning'Location(s) t * , <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified' <br /> yY t :_ , 3 / <br /> Plant Location <br /> 4 Plant Capacity r E, f�+ No. Units Served i <br /> ' 7. ❑ LAUNDRY For Julyi 1, -June 30, 19f ,,. ,. t t r l <br /> SIZE: ❑ Less Than 1,000 Sq.!�Ft_ (] More Than 1,000'S4. Ft.I`� I # { <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t� I c <br /> oelor <br /> hereby certify thaI have prepared this application and that the work will be done in accordance with-San Joaquin County <br /> ordinances, state laws, an ules and re latioras' 4 e San Joagoin Local Health District. i �} <br /> r ^.._� .4 <br /> APPLICANT'S SIGNATURE X � ? <br /> i FOR DEPARTMENT USE ONLY .... - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH' ❑ Janua 1 &Re ved By January 31 ❑ July 1 &Received By Jufy 31 <br /> 7 i - ......._ - .. _ -REMIT <br /> BASE EXPLANATION BILLING REMITTANC AMOUNT DUE CHECKED <br /> i� DATE DATE REMITTED - AMOUNT <br /> FEE r 5ii 5 a.. <br /> LE55 t * I <br /> PRDr4 <br /> RATI0 -_'-, % a <br /> PLUSI: <br /> PENALTY <br /> OTHEROTnl <br /> 16 5 ,5 <br /> r ,. <br /> Received by Date Receipt No ( ;' Perm t'No.,- 'i.c E ssuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> 11 '� - e <br />