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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION / <br /> (For Nan-Transferable, Revocable, and Suspendable) N;- <br /> ENVIRONMENTAL HEALTH PERMIT SEp I'gG& <br /> LIQUID WASTE <br /> Application is eby made t arry,on Usiness in the jurisdictional area of th San aquin Local ealth <br /> In Business Name (DBA) , Address f7 i ict <br /> 1 <br /> z Owner - t <br /> a Address <br /> J Firm Partners, Addresses and T lep one Nu ers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) l 0Title Date <br /> Please check Applicable Category(1-7) and FIII in the Required Information'., <br /> PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 - Disposal Sites - <br /> Description(Make/Yr., Color) - - <br /> 1 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 a� i <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 ocation Test Date/Time <br /> 4. SANITATION PERMIT _ i <br /> Job Ad�Tl <br /> Loc ion <br /> Owner Address <br /> PEPTANK ❑ CESSPOOL '9 LEACHING FIELD SEEPAGE PIT PACKAGE PLANT �g <br /> ERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER ��(�,� e.440 <br /> 5.5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 -l�` <br /> Type Construction Disposal Site <br /> 1 <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 e. <br /> Plant Location s - <br /> Plant Capacity No. Units Served <br /> T'13.LAUNDRY Fo'r July 1, -June 30, 19 , , <br /> SIZE:- ❑ Less Than 1,000 Sq. Ft., - ❑ More Than 1,000 Sq. Ft. ! <br /> ., <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. � k�� f <br /> , .� t t <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 re ` ations he San Joaquin Local Health District. s <br /> APPLICANT'S SIGNATURE X I <br /> .� FOR DEPARTMENT USE ONLY- <br /> fee Is Due: ❑ ANNUALLY ❑ PER-UNIT'_ ;❑-PER SITE ❑ EACH _ ❑"J nuary 1r8 Received By January 31 El July 1 &Received By July 31 <br /> BASE iEXPLANATION BILLIN REM NCE <br /> REM1T <br /> DAT TE REM TTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> f FEE '. <br /> LESS <br /> PRORATION <br /> -PLUS <br /> PENALTY <br /> OTHER <br /> .OTHER <br /> a_ <br /> Received by Date Receipt No. Permit No I 4 <br /> - -�' d"� suance 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 />