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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 /> ENVIRONMENTAL HEALTH PERMIT SI=PTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) /�� 9,V 7— + 54,4-- Address 'd d- 43a r /10 11176 sTo Gs9 <br /> QOwner ± Address - <br /> Firm Partners,Addresses and Telephone Numbers <br /> KCL Business Telephone No. �� 3 _ y 2/ '> Emergency Telephone No. <br /> Contractor Licence No. _ <br /> LApplicants Name (Print) tse .r9wT otic Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required 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. Llccnse 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 /> f No. of Chemical Toilets Stored <br /> f 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> r 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner cTa� Cy.9iyc '� Addressl�s33 <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 11 E]-NEW f ❑ REPAIR ® OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 L <br /> Type Construction ? Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT+ For July 1, -June 30, 1.9 (� <br /> Operator Name y 1 Where Certified <br /> Plant Location <br /> i <br /> r 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 a Co my <br /> j ordinances, state laws, and nos and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> �. FOR DEPARTMENT USE ONLY <br /> r <br /> Fee IS Dile: ❑ ANNUALLY © PER UNIT ❑ PER SITE ❑ EACH ❑ Janua_ry i &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 /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Yec�ei,ed by Date Receipt No. Permit No kssuance Dkile Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601.E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />