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Applications Will Be Processed When Submitted Properlytromwetvu. ou -- <br /> APPLICATION � <br /> _ (For Non-Transferable, Revocable, and Suspendable) s '" <br /> t.t..',.�, ,�SEkTAGE <br /> r ENVIRONMENTAL HEALTH PERMIT <br /> - LIQUID WASTE <br /> ocal�Healkh Dist <br /> Application is erelaypade t car_ on bu ' ess i. the uri tional area of the San Joaquin L <br /> C ! <br /> Address— <br /> OF Business Name (DBA ' <br /> z Owner Address —� <br /> a <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> a. Business Telephone No. � � / 1 <br /> aGi <br /> Contractor Licence No. � E j G Title bate <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Inform tion <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites --- _ <br /> Description(Make/Yr., Color) CRL. License Renewal No. <br /> Serial No. _ CAL. License No. <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 /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. LA <br /> R.S. or R.C.E. Name <br /> Test�ation Test Date/Time— O <br /> 4. SANITATION PERMIT <br /> Job Address/Location 7 j} <br /> Job�OwA AddressLV <br /> SEPTIC TANK ❑ CESSPOO LEACHING FIELD ❑ IT ❑ PACKAGE PLANT <br /> ❑ PERMANENT <br /> ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified N <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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/Amoul <br /> b certify that I have prepared this application and that the work will be done inD dance with San Joaquin County <br /> I hereby Y <br /> ordinances, skate laws, and r s andel regulations of the S n Joaquin Local Health Di c <br /> APPLICANT'S SIGNATURE X I — Y <br /> A <br /> P '. <br /> FOR DEPARTMENT USE LY <br /> Fee IS Due: ❑ ANNUALLY © PER UNIT ❑ PER SITE ❑ EA i anuary 1 &Received By January 31 ❑ July 1 &Recekv By 7JuIY31 <br /> EXPLANATION s BILLING r�i.E ITTANCE $ AMOUNT DUE GBASE DATE DATE REMITTED A <br /> FEE Ls <br /> LESS <br /> PRORATION , <br /> PLUS <br /> PENALTY <br /> OTHER : <br /> OTHER a � <br /> Date ReceiQ No. Permit No. Issuance Date Mailed Delivered <br /> Received by 1601 E.HAZELTON AVE.,P.O.Box 20D9 STOCKTON,CA 95201 _ <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICE5 <br />