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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 �M <br /> LIQUID WASTE <br /> Application is hereby made to cara on business in the jurisdictional area oft San Joaquin Local Health District I <br /> H Business Name (DBA) �g� s� SP— t�00C-_ Address X0-mak It450 -Sn-VIO !95�01 <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. Emergency Telephone No. <br /> j Contractor Licence No. <br /> Applicants Name (Print) - Title _ax? +�� Date P to t <br /> Please check Applicable Category {1-7}and Fill in the Required Information u ` <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. k <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 /> 1-0 PERCOLATION'TEST ` <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> i <br /> Test-Location Test Date/Time <br /> 4. B SANITATION PERMIT <br /> Job Address/Location"-2 1 4-..Ir � <br /> Owner _ S,�'UL-i I Address 1 JL G <br /> ❑ SEPTIC TANK ❑ CESSPOOL OLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> e 1 <br />- ©PERMANENT ❑ TEMPORARY ❑ NEW 21�EPAIR 2"6THER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) 1 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location I <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. ,1( <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. i <br /> I <br /> j <br /> r <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, a rules and reg tions of th n Joaqui ocal H It District. <br /> APPLICANT'S SIGNATURE X - <br /> FOR 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 .j <br /> 4 REMIT 1 <br /> i BASE EXPLANATION BILLING REMITTANCE $ AMOUNT'DUE CHECKED <br /> DATE DATE REWTTED AMOUNT i <br /> FEE vC. <br /> $ �s <br /> LESS _ r <br /> PRORATION [[[ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 :.� 3 <br /> Received by Date - Receipt No Permit No I s an e e Mailed Delivered :F <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH•PERMIT/SERVICES 1601 E.HA2ELTON AYE.,P.O.Sox 2009 STOCKTON,CA 95201 <br />