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APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPT AGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application glereby del r on siness in the jurisdictional area of t �j J uin Local Health Dis rte <br /> liioBusiness Name (DBA)� � 1 _ �!1t�r Address Mir✓ �ta 0 � �✓Tr < �r�+ci� <br /> iOwner Address <br /> Firm Partners, Addresses and Te h ne N er <br /> Business Telephone No. - Emergency Telephone No. <br /> I Contractor Licence No. <br /> c Applicants Name (Print) q Title 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 Gat.,Weights &Measures No <br /> e <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> r For July 1, June 30, 19 <br /> No. of Ve cth5 es Stored <br /> No. of Chemical Toilets Stored \ <br /> t.3. ❑ PERCOLATION TEST ti <br /> R.S.or R.C.E. Name R.S.or R.C.E.No. <br /> Tet cation Test Date/Time ^, <br /> 9..4. SANITATION PERMIT <br /> Job Address cation <br /> O net Address <br /> L4kPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ERMANERTy ❑ TEMPORARY , g NEW REPAIR ❑ OTHER <br /> 5. EI CHEMICAL TOILETS for July 1,-June 30, 19 <br /> Type Constfuction Disposal Site <br /> No. of Units „- Equipment Storage/Cleaning Location(s) _ 1+ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 e <br /> Operator Name ` Where Certified <br /> Plant Location <br /> 1 yt <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 /> r❑.DRY CLEANING,Chemicals Used/Amount/Mo.l. , <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,alnd rules and reg lations Q`Saran J'A/a in Local Health District. <br /> V APPLICANT'S SIGNATURE X l.d !E"�..{ 2 <br /> 1r FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ OHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE FEE I <br /> Xly\�v <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> pp OTHER <br /> 6 OTHER hh��/ <br /> ReceiveC by Dale Receipt No, Perm No. Issuance Data McJetl Delivered <br /> I♦ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES, '��1601 E.HAZELTON AVE.,P.O.Sos 2009 STOCKTON,CA 95291 <br />