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t <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspenda T ENVIRONMENTAL HEALTH PERMIT ' I� Y[.i`�tJ "��� <br /> a LIQUID WASTE <br /> Applicatio is hereby made to rry on business in the jurisdictional area of the San Joaquin Local Heal District/ <br /> ,�Business Name {DBA} It-°�(1 G Address 30 .0 vo; <br /> aOwner_ i=Z S � tt� Addre s <br /> Firm Partners, Addresses and Telephone Numbers rrVV,C14sf yh� <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title kV Date <br /> Please check Applicable Category (1-7)and Fill in�theRequired 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 a <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 R.S. or R.C.E. No. <br /> Test 4ocation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Addre s/Location <br /> Owner Q-"Q_ Address <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT �J <br /> PERMANENT ❑ TEMPORARY NEW C1 REPAIR '.OTHER /yr <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <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 <br /> Plant Location <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 f`' <br /> I hereby certify that I ave ep thi plic n d that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws and r Is d reg n f t 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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ IUNlg� T DUE CHEC ED <br /> DATE DATE REMIT ED AMO T <br /> FEE ��� ---- <br /> LESS <br /> PRORATION <br /> PLUS — —__ __ <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dale Receipt No Permit No. Issuance Date Mailed Deli/I red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />