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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) S <br /> ENVIRONMENTAL HEALTH PERMIT SI PTAG� <br /> LIQUID WASTE <br /> Application i r mad car n business in the jurisdictional area of the San Joaquin Local Health District <br /> w Business Name (DBA) D Address �� '� -�� 'ey r <br /> a Owner-4-A, &)Lzz 2 s- ' Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title I �' Date f <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> l 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> i For July 1, June 30, 19 Disposal Sites �A <br /> r Descripfioh(Make/Y.r:, Color)"�* "� - <br /> Serial No, CAL.License No. CAL. License Renewal No. <br /> Capacity Gal., Weights&Measures No. \\\ <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> I For July 1, June 30, 19 <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. <br /> Test Location Test Date/Time Q <br /> 4. W--SANITATION PERMIT <br /> Job Address/ ocation <br />` Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL 15'-LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW XfREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site rs <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 p red hi pplic tion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, arr6'rul a r gulatio the Sa oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 0-_ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & ceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION . AMOUNT DUE CHECKED <br /> DATE DAT REMITTED <br /> {• AMOUNT <br /> FEE 66 <br /> LESS ( V <br /> PRORATION ILI Ktv� <br /> _ <br /> PLUS <br /> PENALTY IF e <br /> OTHER <br /> OTHER <br /> i <br /> I - a\-�� <br /> Received by Date Receipt No. Permit No. Issuance D Mailed Delivered <br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTO .,P.O.Boa 2009 STOCKTON,CA 95201 <br />