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Applications Will Be Processed When Submitted Properlycomplelea. oe :yure I <br /> APPLICATION <br /> ` (For Non-Transferable,Revocable, and Suspendable) S TAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is erek y made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> 4ABusiness Name (DBA) , Address <br /> z Owner Address <br /> 9 <br /> U firm Partners, Addresses and Telephone Numbers <br /> a f2 . Emergency Telephone No. <br /> a. Business Telephone No. —�6 <br /> JContractor Licence No. _ <br /> L Applicants Name (Print) 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) – lxs- / <br /> CAL. License Renewal <br /> Serial No. CAL. License NO.'- _ No v� <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 — <br /> No, <br /> 9 No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST E <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location <br /> Test Date/Time <br /> 4. 11 SANITATION PERMIT ©/V t. 5 ✓L <br /> Job Address/Location v Q <br /> Owner Address af <br /> P"S'EPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR 0 OTHER' <br /> 5.. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 : r <br /> Type Construction Disposal Site \\\ <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> - `- - Where Certified <br /> Operator Name d <br /> 1 <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 /> X <br /> I hereby certify that l have prepared-this•-application and-that the work will be done'in accordance with San Joaquin County <br /> ordinances, state laws, and rules and reg ations f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X e <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> �v <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> f" OTHER' <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />