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F Completed. ueSure iv Div.. rte' t <br /> Applications Will Be Processed When SdAPPL`CATION <br /> (For Non-Transferable, Revocable, and Suspendable) SE.PTAGE C <br /> J ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE }� <br /> �. GCi O77 i <br /> Applicat n is hereby made to carryon business in the jurisdictional area of the San <br /> ©��In Local Health District <br /> �F 5+�kuIGLG Address L <br /> F Business Name {DB ) Address `5 <br /> z Owner Cad <br /> a <br /> 2 Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> aBusiness Tel No. f <br /> Contractor Licence No. Title Date <br /> �Applicants Name (Print) <br /> Please_check Applicable Category (1-7) ani!Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, <br /> June 30, 19 Disposal Sites <br /> Description{Make/Yr., Color} CAL. License Renewal No. 1 <br /> CAL. License No. <br /> Serial No. <br /> Capacity Gal.,Weights &Measures No, <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, i9 <br /> J, <br /> 'No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> F,S. or R.C.E. Name Test Date/Time <br /> Test Location [�I <br /> 4, ® SANITATION PERMIT �y1=7— <br /> Job <br /> TJob Address/Location Address <br /> Owner1112 <br /> ❑ PACKAGE PLANT <br /> 1:1 SEPTIC TANK 11 CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ OTHER <br /> PERMANENT <br /> ❑ TEMPORARY ❑ NEW ® REPAIR <br /> t <br /> ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> 5. Disposal Site <br /> Type Construction <br /> Equipment Storage/Cleaning Location{s) <br /> No. of Units <br /> g. ❑ PACKAGE TREATMENT PLANT For July 1,- June 30, 19 Where Certified <br /> Operator Name <br /> } Plant Location No. Units Served <br /> Plant Capacity <br /> k 7. C3 LAUNDRY For July 1, -June 30,0 More Than 1,000 Sq. Ft. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that 1 have prepared this apolic ti the d thatan theJoaquin Local ill betdone District.tin accordance with San Joaquin County <br /> ordinances, state laws, .and regu <br /> l <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> j Fee is Due: ❑ AT PER UNIT ❑ PER SITE REMITTANCE $ MOUNT DUE CHECKED <br /> F BILLING <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> ( LESS <br /> f PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> l OTHER ,f <br /> F Issuance Date Mailed Delivered <br /> I Receipt No. Permit No. STOCKTON,'CA 95201 <br /> + Received by Date <br /> f APPLICANT—RETURN ALL COPIES TO: ENVIRO��TA�HEAD PESEAYICES �� �,HAZELTOf �%12909 <br />