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{ Applications Will Be Processed When SubmittedPropeny%,ulmN— ' <br /> 4.. APPLICATION / <br /> (For Non-Transierable, Revocable,and Suspendable) SEPT.gGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereb�mad�to carry oon business in the jurisdictional area of the San Joaquin Local Health District <br /> u L Address <br /> rn Business Name (DBA) Address _ <br /> z Owner <br /> U Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> s Business Telephone No. _ - <br /> 17 <br /> j Contractor Licence No. Title Date 1 <br /> L Applicants Name (Print) V" <br /> ill in the Required Information <br /> Please check Applicable Category (1-7)and F <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, <br /> June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Calor) CAL, License No. CAL. License Renewal No, <br /> Serial No. <br /> Gal., Weights & Meassi'2�-N <br /> Capacity tl <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July.1, June 30, 19 r <br /> No. of Vehicles Stored <br /> s. <br /> Na. of Chemical Toilets Stored € <br /> 3, ❑ PERCOLATION TEST „ R.S. or R.C.E. No. <br /> or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT <br /> ,lob Address/Location r C <br /> ' '� - .Address <br /> Owner (��ACHING FIELD C3 SEEPAGE PIT El PACKAGE PLANT <br /> 01 SEPTIC TANK ❑ CESSPOOL 13 REPAIR <br /> 13 OTHER <br /> ❑ PERMANENT ❑ TEMPORARY 13 NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site <br /> Type Construction '�— <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> r <br /> Operator Name ti <br /> Plant Location No, Units Served - <br /> Plant Capacity <br /> 7, ❑ LAUNDRY For July 1, -June 30,•19 -, <br /> SIZE: 11 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq- Ft. <br /> ❑ DRY CLEANING, Chemicals Used/AmounVMo. C <br /> ty <br /> 1cation^and that the work will be done in accordance with San Joaquin Cound <br /> I hereby certify that k have prepared this application <br /> state laws, and rules an re tions of the San Joaquin Local Health District. <br /> ordinances, <br /> APPLICANT'S SIGNATURE X r <br /> FOR DEPARTMENT USE ONLY <br /> ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee IS Due: ❑ ANNUALLY REMIT <br /> CHECKED <br /> BILLING REMI NCE $ AMOUNT DUE <br /> BASE EXPLANATION DATE E REMITTED AMOUNT <br /> FEE f f <br /> LESS ' f <br /> -PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7]� <br /> ZS Mailed Deiivere <br /> Date Receipt TA <br /> Permis No. suanc Date <br /> Received by t601 E.►4AZELTON AVE..P.O.60=2009 STOCKTON,CA 952 <br /> 01 <br /> APPLICANT—RETURN ALL COPIES 70: ENVIRONMENTAL HEALTH PERMITlSERVICES <br />