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Applications Will Be Processed When Submitted Properly Completed. BeSureTo sign <br /> APPLICATION <br /> (For Non-Transferable, Revocable,'and Suspendable) S> PTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati n is hereby made to carry on business in the jurisdictional area of the San Joaquin cal Health lite <br /> Address <br /> yBusiness Name (DBA) <br /> z Owner Address <br /> J <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No., <br /> a <br /> Business Telephone No. I <br /> a ... <br /> . . <br /> Contractor Licence No. _r -:. � P�Il? Date tet~ <br /> ., Title <br /> Applicants Name (Print •' , <br /> Please check Applicable Category (1-7)_and Fill in the Re iced Information .i, t '1-: <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, June 30, 19 Disposal Sites. <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License 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 R.S.or R.C.E.No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. ;4 SANITATION PERMIT - <br /> Job Address/Location 1071% ?� <br /> IOwner Address <br /> SEEPAGE PIT--N 13PACKAG PLA T �/ t� <br /> ❑ SEPTIC TANK 11 CESSPOOL ❑ LEACHING FIELD ❑13 NEW REPAIR E] OTHER %Qd [� V} Q PI1- C <br /> ❑ PERMANENT ❑ TEMPORARY <br /> 1 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ii ,' <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 Where Certified - <br /> Operator Name O <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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. hls)ssurd,l natemplayanypm O <br /> a y tAattelAspwnmlattcsOfttfewatittorert�il�►fiis9et _ <br /> Nomeo "Worlicemwdagene•s�m 1lrbW 4f�fCtt4lp <br /> in swh manner as to become sub!eCt c.ro".s Ole fQ"W#h*. {etlstAi 4Aat 341 thll pJrhtuWC6 4f ft work Its'W110 alis.Permit is <br /> issaed•l slsau <br /> COM McWt's or sub e 9 <br /> employ persons sAect to workman'3 campe tatr la++Vs of Cafiivrnia" <br /> hereby certify that I have prepared this applicahandn at <br /> work <br /> ill be done in District.accordance with San Joaquin County <br /> ordinances, state laws, a rules and regul q+ y <br /> APPLICANT'S SIGNATURE _ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT, ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEBy July 31 <br /> BILLING REMITTANCE s AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION // <br /> PLUS �( .• !'� �� l y..7z <br /> PENALTY 1�(, <br /> OTHER <br /> OTHER <br /> I Y C <br /> 1 Iss ante Date Mailed Delivered <br /> Received by Date <br /> Receipt No4 Permit No. ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> -1601 E.HAZELTON AVE.,P.O.Box 2909 STOCKTON,-cA 95201 <br />