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Applications Will Be Procesb—When Submitted Properly Completed. Be Sure ._dign The Application. <br /> APPLICATION <br /> (For Non-TranlFl"r 01e;Rgi0table, and Suspendabte) <br /> ENVIRONMENTAL. HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to ca ry Qn business in thq jurisdictional area of the San oaq 'n Local Health District y <br /> Business Na e (DBA �-`� !nr -' AddresseX 3�y W. <br /> 152 <br /> i Owner L1 'l U� S Address G C�t i4N .S fig 4 Os1 S li . /1D(�s� <br /> aFirm Partners, Addresses and Telephone Numbers vL .� `� 5 2/ 7J <br /> Business Telephone No. �j}�c�(% Emergency Telephone No. <br /> Contractor Licence No. <br /> a <br /> Applicants Name (Print) L Title 5 1 � 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) <br /> Serial No. CAL. License No. CAL. License Renewal 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� <br /> R.S. or R.C.E. Name r%/� �" CL FLLG R.S. or R.C.E. No. LL �' ��r'✓� ___ <br /> Test Location 5�� S r �� �� Tact Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location _ <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ 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 Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <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/AmounUMO. --- <br /> I 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. <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> a„ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER / <br /> I.R <br /> eceived by Date f Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />