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Applications Will Beeased When Submitted Properly Completed. BI •e To Sign The Application. <br /> �' APPLICATION <br /> --�� (For Non-Transferable, Revocable, and Suspendable) f Y <br /> ENVIRONMENTAL HEALTH PERMIT k <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> x/ a, r!.,v� ,Q <br /> O Business Name�DBA) Address -' a 4? �='— <br /> iOwner. �t 7c'.UA�U(���C P Ile "- Address L' <br /> Firm Partners, Addresses and Telephone Numbers - -..... — - --- ----- - -- - <br /> a. Business Telephone No. � Emergency Telephone No.---- <br /> Contractor <br /> o._ _-Contractor Licence No. _ —---- --- <br /> Applicants NamDate <br /> Please check Applicable Category(1-7)and Fill fr1the 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 Gat., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD [ f <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored --- - --- <br /> No.of Chemical Toilets Stored ------ <br /> 3',9•PERCOLATION TET �* <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. a <br /> Test Location ' Test 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/Amount/Mo. — ------ -- _ <br /> I hereby certify that I have prepared this applic io nd at the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. <br /> APPLICANT'S SIGNATURE X Title �`/ L f7 Date J� . <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑July 1 5 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE - $ AMOUNT DUE "CHECKED <br /> DATE DATE REMITTED AMOUNT_ <br /> FEE ►L U L 3-3� �; ��z. �� <br /> LRss <br /> PRORATION ,-- <br /> PLUS <br /> PENALTY U <br /> OTHER <br /> OTHER G <br /> 77 <br /> Received ` Danes Z- Receipt No Perm+t No Issuance Data Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERFAITlSERVtCES 1601 E.HAZELTON AVE.,P.O.Box 2002 STOCKTON.CA 95201, <br />