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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 Suspendable) <br /> ,., 51wp7AGE• <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE } sty <br /> Application I hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District. <br /> yBusiness Name (DBA) - i Z ��� t Address <br /> aOwner _.- Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business,Telephone No. �(e —�(a a7 - Emergency Telephone No. - <br /> a �- � <br /> Contractor Licence No. S4- <br /> Applicants Name (Print) - t Title ^`- <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> n <br /> 1. 0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) W <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.,Weigh st & Measures No. T <br /> Equipment Parking Address __ } <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 1% 3`•r <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. 4 <br /> Test�Loo tion t } Test Date/Time i <br /> 4. � SANITATION PERMIT. <br /> Job Address/Location <br /> Owner 'K ' — Address <br /> Address <br /> ❑ SEPTIC TANK ❑;CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> aPERMANENT ❑ TEMPORARY ❑ NEW 0 REPAIR ❑ OTHER Cl'� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 CS' <br /> Type Construction Disposal Site f <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT -FoT,fuly 1, -June 30, 19 M s <br /> Operator Name + �. ""'''"Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served r "' <br /> 7. El LAUNDRY For July 1, -June 30, 19 1-r <br /> SIZE: ❑ Less Than 1,000 Sq! Ft., ❑ Mole Than 1,000 Sq.-Ft. <br /> ❑'DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 4e <br /> c <br /> I hereby certify that I have.prepared this applicat, and that the'work Will'.be done in accordanl:•e'wiih�San-Joaquin County -= <br /> ordinances, state law, a d r es and re plationa f Ae 5a oa ui ocal Health District. -» <br /> APPLICANT'S SIGNATURE y s <br /> FOR bEPARTMENT USE ONLY <br /> r r <br /> Fee Is Due: C1 ANNUALLY.,` .b P,ER UNIT., _'❑ PER SITE �`❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT , <br /> BASE lea. I`EXPLANATION PATE DATE REMITTED AMOUNT DUE AAhOUND <br /> r I <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS _•.: .. I ._ <br /> PENALTY <br /> i <br /> .1 OTHER <br /> OTHER t a <br /> Received by Date Receipt No. Permit No. ISSuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> .. I <br />