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Applications Will Be Processed When Submitted rope <br /> App i APPLICATION <br /> .? (For Non-Transferable, Revocable, and Sus <br /> pendable) $EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE r <br /> . P <br /> Applicatio her y to carryon business i��� sdictional area of the San Joaquin aquical He th District <br /> Address <br /> 0 <br /> yBusiness Name {DBA) G Address <br /> z Owner <br /> 4 Emergency Telephone No. } . <br /> 9 Firm Partners, Addresses and Telephone N�bets <br /> if <br /> ♦ fij <br /> I <br /> Business Telephone No. J Date. <br /> Contractor Licence No. t Title ` <br /> Applicants Name (Print) <br /> j 7 and Fill in the Required Information <br /> Please check Applicable Category (1- ) <br />� PERMIT REGISTRATION-(FOR EACH VEHICLE) <br /> i, ❑ PUMPER VEHICLE <br /> Disposal Sites <br /> For July 1, <br /> June 30, 19 <br /> Make/Yr.,Color) CAL. Lic4 se Renewal No. <br /> Description{ CAL. License No. <br /> Serial No. 160.l <br /> Gal.,Weights $�Measures No. <br /> Capacity . <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 /> j 3, ❑ PERCOLATION TEST R.S.or R.C.E. No. <br /> t R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. SANITATION PERMIT <br /> Job Address/Location Address ❑ PACKAGE PLANT <br /> Ownerw LEACHING FIELD SEEPAGE PIT ❑ OTHER ' <br /> El SEP TIC TANK ❑ CESSPOOL NEW REPAIR <br /> i 51 PERMANENT C3 TEMPORARY 13 <br /> M 5. 0 CHEMICAL TOILETS For July 1,-June 30, 19 <br /> tt <br /> Disposal Site <br /> Type Construction <br /> Equipment Storage/Cleaning Location(s) � <br /> No. of Units <br /> g. ❑ PACKAGE TREATMENT PLANT For July ,1, - June 30, i9o <br /> Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, - June 30, 109 <br /> 1,000 Sq. Ft. <br /> ❑ Less Than 1,000 Sq. Ft., <br /> i SIZE: <br /> ❑ DRY CLEANING, Chemicals.Used/Amount/Mo. <br /> i t/4 <br /> j application and that the work will be done in accord nce with San Joaquin Country <br /> ` l hereby certify that I have repared this aPP the S Joaquin Local Health District. <br /> ordinances, state la x, n tui and regulatio <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPART EN USE ONLY <br /> ❑EACH Sanuary 1 &Received By January 31 ❑ July 1 S Received 13y July 31 <br /> REMIT <br /> Fee Is Due: ❑ ANNUALLY' ❑ PER UNIT ❑ PER SITE REMITTANCE $ AMOUNT DVE CHECKED <br /> I. BILLING REM4TTEO AMOUNT <br /> BASE' EXPLANATION DATE DATE <br /> I A <br /> ' FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I OTHER fi <br /> Issu nce Date STOCKTON,CA 95201 <br /> Mailed Delivered <br /> ( - Rec - Permit No, - <br /> Received by Date 1Bo1 E.HA2ELTON AYE.,P.O.Box 2009 - <br /> eipt No <br /> APPLICANT—RETURN ALL COPIES TO: £NYIRONMENTALHEALTH PERMITlSEAYlCES., i+ <br />