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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> t (For Non-Transferable, Revocable,and Suspendabie) <br /> ENVIRONMENTAL HEALTH PERMIT 5EPTAGE <br /> LIQUID WASTE <br /> Applicati is hereby made to car on business in the jurisdictional area of the San Joaquin ocal He th <br /> Business Nam DBA -- Address / B <br /> i Owner _t4 - �' _ Address d —'? <br /> O Firm Partners, Addresses and Telephone Numbers --lim.,. Wd- - e', - <br /> T < Business Telephone No. b _ Emergency Telephone No- <br /> Contractor Licence No. <br /> Applicants Name (Print)) 1 1 k �L� -� G.� _ Title � �--- - Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information / <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 { Disposal Sites - <br /> Description(Make/Yr.. Color) - - <br /> 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 /> I No. of Vehicles StoredNo.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,,Lo5'atIon Test Date/Time <br /> C 4. SANITATION PERMIT 1 F LN <br /> Job Address/LocatI n - 0 16d C <br /> Ow r mQ in[ s e K ...P-rT�4,1r, ddress r <br /> C7 IPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT �n <br /> ' IWPERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No of Units _. Equipment Storage/Cleaning Location(s) <br /> B- ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> I Operator Name Where Certified <br /> i Plant Location —- --- ---- --- <br /> 7�i <br /> Plant Capacity — __ No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 36, 19 <br /> I1 SIZE: ❑ Less Than 1,000 Sq_ Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - — - <br /> I " <br /> I ' <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, rules and regulatiionss�offthe San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> ? FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 . <br /> 1 ` REMIT <br /> BASE EXPLANATION RILLING REMITTANCE ; AMOUNT DUE CHECKED <br /> DATE DATE REMITrED- AMOUNT <br /> FEE � -. - ------ - — <br /> `. LESS <br /> PRORATION <br /> PLUS <br /> t PENALTY <br /> OTHER <br /> �fir i <br /> OTHER <br /> 6 fvvoq(e S <br /> Received by 'Date _ , �..ReceiplNo Permit No su9n a Uate Mailed Delivered <br /> I - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTHPERMIT/SERYICEs 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />