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r�NYu..u.,v u.a ♦r n, vc ,...-..w.... ..,,�„ ...+..nu,..... , ,...�... ,l vv,.p..�...... -... .....� ... .�.. .._ r,Y...,_..�... <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on by_5pess in thejurisdirtional area of the Sang/oaq Local Health DSI�-.rlct <br /> N Business Name (DBA) <br /> r- <br /> • =� -E= e� /�-»- 4' ,54� Address <br /> i Owner Address <br /> } Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. aEmergency Telephone No. �l <br /> Contractor Licence No. _. t, Ilk 7: <br /> a Applicants Name (Print) '' ` �'��. Title r� Date « �G d' I <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> .S <br /> moi. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> _.For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> VSerial No. CAL. License No. CAL. Licc.-ise Renewal No. <br /> Capacity Gal., Weights & Measures No. ' <br /> Equipment Parking Address <br /> 6.2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> — No. of Vehicles Stored <br /> No- of Chemical Toilets Stored <br /> 6W3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Tesation Test Date/Time <br /> ..,4. SANITATION PERMIT <br /> Job Address/ILagatinn 11.641 <br /> Owner10, Address ' <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELDS EPAGE PIT ❑ PACKAG PLANT <br /> *"❑ PERMANENT ❑ TEMPORARY ❑ NEW V REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ~C <br /> Type Construction Disposal Site <br /> 6*No- of Units Equipment Storage/Cleaning Location(s) �F <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 L I <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 /> 6. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rul s and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED V <br /> AMOUN <br /> FEE ` <br /> LESS 1 <br /> 1` PRORATION <br /> PLUS U <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I <br /> '7 r' C— <br /> L � 131--, _--) <br /> i Received oy Date Receipt No Permit No issuilince Dates Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT.'SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON.CA 95201 <br />