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w Applications Will Be Processed When Submitted Properly Completed. Be Sure10 sign IneMVP++L'au.,',. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) 5EP7AGE , <br /> ENVIRONMENTAL HEALTH PERMIT <br /> f LIQUID WASTE ' <br /> Application is reby,,made t C on fine sin the juri fictional area of the Sa oa in Local Health DWrAct e <br /> .. Address <br /> Business Name A) <br /> z Owner Address ' <br /> K <br /> J Firm Partners, Addresses a d Telephone Numbers Emergency Telephone No. <br /> CL <br /> Business Telephone No. <br /> '/Q <br /> Contractor Licence No. Date <br /> Title + <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill in t e Requ d Information �^ 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EA H VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. Lic-;1se Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal., Weights &Measures No. <br /> 1 <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored I <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location t <br /> 4. ❑ SANITATION PER IT 1 t <br /> Job Address/Locationj � X u <br /> Owner r Address <br /> ❑ CESSPOOL ❑ LEACHING FIELD S EPAGE PIT PACKAGE PLANT <br /> ❑ SEPTIC TA ❑ DTHER j <br /> ❑ PERMANENT ❑ TEMPORARY xl❑ NEW REPAIR <br /> 5. 11 CHEMICAL TOILETS For July 1, -•June 30, 19 C/IJ <br /> I .f Disposal Site <br /> Type Construction Z <br /> No. of Units Equipment Storage/Cleaning Location(s) ' <br />€ B. ❑'PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified.''4 <br /> Operator Name „C <br /> Plant Location -Z <br /> Plant Capacity No. Units Served <br /> S <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 /> 4. <br /> I hereby certify that I have prep red this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ru nd reg lati ns ofIt Sa Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE O <br /> 'Fee Is Due' ❑ ANNUALLY C-1PERUNIT" ❑ PER SITE [I EACH anuary 1 & e ed By January 3t July 1 R Received By July 31 - <br /> REMIT <br /> I BILLING MITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DAT REWTTED AMOUNT <br /> FEE s <br /> LESS r <br /> PRORATION - <br /> PLUS <br /> t PENALTY <br /> OTHER <br /> I. r� <br /> OTHER <br /> Rec ' Permit No. Iss ance Date M ed Delivered <br /> Received by Date - <br /> 1601 E.HAZELTON AVE.,P. 2099 - STOCKTON,CA 95201 <br /> ' APPLICANT_RETURN ALL COPIES TO: ENVIRONMENTAL Hi CES <br />