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/ Applications Will Be Processed When Submitted Property Completed. Be Sure TO Sign The e p licatip <br /> elC . <br /> / / APPLICATION <br /> �' •a�`as 9 (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEP <br /> TAGE ~� <br /> LIQUID WASTE <br /> i Applicat' n i's here b ma a to car ugin ss the jur's conal area of th qn Lo al al h District <br /> F Business Name {DBA) ' ti <br /> � , an o ui <br /> a Owner L ddry�s <br /> Firm Partners,Addresses e Address v�e1 <br /> ephrone Nu�rlber <br /> IL Business Telephone No, <br /> Contractor Licence No. Emergency Telephone No. ; <br /> a , . <br /> L Applicants Name (Print) - <br /> Please check Applicable Categoion Title Date �' ' <br /> ❑ PUMPER VEHICLE PERMIT( <br /> (FOR EACH VEHICequired tLE) <br /> For July 1, June 30, 19 <br /> Disposal Sites. <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. " <br /> Capacity �" „� `_ <br /> 'CAL. License Renewal Na. <br /> r � �Gai:, Weights & Measures No. _- <br /> Equipment Parking Address <br /> f 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 <br /> Test Location R.S.or R.C.E. No. <br /> Test Date/Time # <br /> j 4. ❑ SANITATION PE MIT <br /> I Job Add, s/Location <br /> b Owner r <br /> ❑'SEPTIC TANK CESSPOOL �❑ LEACHING FIELD re❑ r <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW SEEPAGE PIT ❑` PACKAG PLANT <br /> $ '❑ CHEMICAL TOILETS"Fvr'July,,1; =June 30, 19 REPAIR ❑ OTHER <br /> Type Construction Disposal Site e <br /> No: of Units Equipment Storage/Cleaning Locations _ T ! <br /> 6..a❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 { ) ) <br /> f Operator Name <br /> Plant Location Where Certified <br /> Plant Capacity --- - <br /> 7• E❑ LAUNDRY For July 1, -June 30, 19 No. Units Served <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> tt : <br /> I hereby I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, stafe laws d rules and gula ' n <br /> The San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> PO DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY PER UNIT � <br /> -.❑ PER SITE ❑ EACH - <br /> ❑ January 1 &Received By January 31 ❑ Jul 1 R <br /> .. Y Received By July 31 I <br /> BASE `, EXPLANATION BILLING R.EMITTANCE r $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE } _ <br /> a `� AMOUNT , <br /> LESS �s £ <br /> f <br /> PRORATIONi <br /> PLUS <br /> PENALTY ' <br /> i <br /> �. OTHER <br /> OTHER - •,!' <br /> Received by Date ' <br /> Receipt No. Permit No. �— - <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTIiPEWIT/SERVICES -` Issuance Date Mailed Defivered + <br /> ` 1601 E.HATELTON AVE.,P.O.Bg� / STOCKTON,CA 95201. <br />