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Applications Will.Be Processed When Submitted Properly Completed. Be Sure To Sign:The Application. <br /> APPLICATION �-� <br /> (For Non-Transferable, Revocable,and Suspen ab e) y <br /> " SE PTAG E <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> E r ," App 'lication hereby made to carryon business in the jurisdictional area of the Sa Joa uin Local Health District <br /> ,F-Business Nam DBA) Address �� <br /> i.Owner Address C i\ <br /> �e: Firm Partners, Addresses and Telephone Numbers n� <br /> a-Business Telephone No.. Emergency Telephone No. i <br /> Contractor Licence No. <br /> L Applicants Name (Print, Title Date 2—IF <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 /> + <br /> ,Description CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> j Equipment Parking Address <br /> 2. ❑ PUMPER YARD r, <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PER_COLATION TEST %--••» -�-�w-^ ----- <br /> R.S. or R.C-E. Name R.S. or R.C.E. No. + <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT rp-. <br /> Job Address/Location <br /> Owner '1-c >fi ) „ vY Address r°L6 CLu `�� <br /> ❑ SEPTI ANK I ❑ CESSPOOL ❑ LEACHING FIELD ❑ ❑ PACKAGE PLANT 0 <br /> t ❑ PERMANENT ❑ TEMPORARY F❑''NEW ®REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS. Foy July 1,-!June 30, 19 �y <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) `�'•- _ <br /> ..� <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name —Where Certified <br /> Plant Location <br /> z Plant Capacity -i- 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 /> 5 �! <br /> I hereby certify that I have prepared this application and that the work will be done in occordanA with San Joaquin County <br /> ordinances, state laws,�an l rules and r lations of the San J aquin Local Health Distric <br /> APPLICANT'S SIGNATURE <br /> e <br /> .I+ <br /> FOR DEPARTMENT USE ON <br /> iFee Is Due: 11 ANNUALLY I1 ❑ PER UNIT' 11 PER SITE E] EACH ElJanua Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTAN $ <br /> BASE ; EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S t <br /> LESS <br /> PRORATION �I <br /> PLUS 's <br /> PENALTY <br /> } <br /> OTHER <br /> OTHER <br /> 2 <br /> Received by Date.i Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES Til; ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box`2009' STOCKTON,CA 95201 <br />