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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ! � <br /> 71 <br /> a® <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) ��' <br /> . SE'1:AGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is h�/Q�feby made to carry on business in the jurisdictional area of thAAe San Joaquin L'o/�al Health District q�^ <br /> ,A�iQ1�� �0 S =A Address/� 9Dk <br /> rn Business Name (DBA)P—A —T— <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. ^ 9� Emergency Telephone No. <br /> _J Contractor Licence No. ZS�4< 3 y� ct <br /> Applicants Name (Print).. y ��'�$ Title Date 7-20 �d <br /> Please check Applicable Category(1-7)and Fill in the Required Information C' <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 /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name <br /> R.S.or R.C.E. No. <br /> Test�Loc�at'on Test Date/Time <br /> 4. I� SANITATION PERMIT t <br /> Job Address/Location /7414;19 5, <br /> Owner .1®s,[+U 'e©SSS Addresses X'° <br /> ®'SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 1:1 TEMPORARY ❑ NEW ❑ ❑ OTHER <br /> �l <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 /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location a <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. <br /> I hereby certify that I h e prepared his appli tion and hat the work will be done in accordance with San Joaquin County <br /> ordinances, state la n r gulatio f the n Joaquin Local Health District. <br /> APPLICANT'S SI�NATURE <br /> DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ P SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> z1'r� <br /> FEE r .v <br /> LESS <br /> PRORATION <br /> PLUS / <br /> PENALTY <br /> AA <br /> OTHER <br /> OTHER <br /> 7 <br /> Received by Date Receipt No: Permit No. Issuance Date Mailed Deliver d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />