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Applications Will Be ProcessedWhen SubmittedProperlycompietea.eie'sure tosign meplppucano 7 <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) 1 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F business Na e ( A) Addre s <br /> Owner Address <br /> Firm Partners, Addresses and Telephone Numb rs <br /> business Telephone No. �d 6 Emergency Telephone No. <br /> Coritfactor Licence No. <br /> L Applicants Name(Print) k�A Title ��nyyr- Date <br /> Pleese check Applicable Category (1-7) and Fill in the Required Information <br /> fr ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Descflption(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 R.S. or R.C.E. No. f <br /> Test Location Test Date/Time <br /> 4, KSANITATION PERMIT <br /> Job Address/Location <br /> Owntlr Address <br /> ❑ SEPTIC TANK ❑ CESSPOOLLEACHING FIELD ❑ SEEPAGE PIT 13PACKAGE PLANT <br /> 11PERMANENT 11TEMPORARY 21NEW ❑ 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 /> 6. Q PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Platt Location <br /> Plant Capacity No. Units Served <br /> 7. Q 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 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ��- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ElANNUALLY ElPER UNIT E] PER SITE ❑ EACH 13January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DTE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS ' I <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E,HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br /> fr <br />