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ApplicationsWIT] lie ProcesseffW"en SubmittedProperlyCompleted. HeSureTo SignTheApplication. <br /> APPLICATION <br /> (Por Noh-Transferable, Revocable, and Suspendable) <br /> --� tNVIRONME:NTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application 'S hereby made to carry on business in the juriMictional area of the San Joaquin Local Health District <br /> N Business Name (DBA} Address- � y�.:2 /.2 4 P 1 2/ z � .-.41��� <br /> z Owner Address m <br /> a <br /> u Firm Partners. Addresses and Telephone Numbers__ <br /> Business Telephone No ��7L7'f <br /> S$ Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) ✓�• aGG�� Title Date <br /> Please check Applicable Category(1-7)and Fill In the F1djulred 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 /> Serial No. CAL. License No. CAL, License Renewal No. <br /> Capacity Gal, Weights A Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> iF No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test,,LoXion Test Date/Time <br /> 4. t!7 SANITATION PERMIT _ r <br /> Job Address/Location .219 <br /> y ,O,,wn�r J t ���n�r __ Address <br /> L7 SEPTIC TANK C1CESSPOOL ®L ACHING HELD �€EPAGE PIT ❑ PACKAGE PLANT <br /> O PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Dispost;l Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name __... Where Certified <br /> Plant Location - <br /> Plant Capacity ____—_ 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 /> 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 an egulations of the Sa Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X -- <br /> r <br /> POR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> /a C AMOUNT <br /> L <br /> FEE oh t? <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER �p <br /> Received by I 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 /> 5 <br /> i <br />