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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SE PTAGE <br /> f ' ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby ade to a on business in the jurisdictional area of the San J aquin cal He is •ict <br /> NBusiness Na (DBA} l & r - Address <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Tele hone Numbers <br /> IL <br /> Business Telephone No. Emergency Telephone No. <br /> a.d / t� <br /> ..Contractor Licence No. r Date <br /> Applicants Name (Print) Title <br /> Please check Applicable Category (1-7) and Fill in the Required Information y <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. Liccnse Renewal No. <br /> Serial No. CAL. License 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. Na. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT Q <br /> Job Address/Location <br /> O,.--w,rrner A ress <br /> L�'SEPTIC TANK 11 CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ REPAIR EJ OTHER <br /> �ERMANENT ❑ TEMPORARY 13 NEW <br /> 5. 1:1 CHEMICAL TOILETS For Ju 1 -June 30; 19 ram/J <br /> Type Construction Disposal Site <br /> A. <br /> No. of UnitsA -�°*"'t-Equipment Storage/Cleaning LocatiTn(S) <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> I Plant Location <br /> 771 <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 /> E � <br /> F I hereby certify that I have prepared this application and that the work will be done in accordance Joaquin County <br /> ordinances, state laws, and rules and regulatio of the San Joaquin Local Health Ic <br /> APPLICANT'S SIGNATURE X <br /> w (5 G <br /> FOR DEPARTMENT USE ONLY <br /> Feeds Due: ❑ ANNUALLY Y. PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received Bnyl July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ATE DATE REMITTED AMOUNT <br /> FEE qso-o- <br /> LESS <br /> pI` PRORATION �y <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 16 -7q 1571 .) -- <br /> I Received by ate Receipt No. Perrnit No. Issuanc Mailed Delivered <br /> A41.ICANT—'RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1801 E.HAZEL E.,P.O.Bo■2009 STOCKTON,CA 05 <br />