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I Applications Will tae Yrocessea When Submitted Property Gompietea. tse Sure I sign 1n Application. <br /> APPLICATION /1-1 <br /> or Non-Transferabie, Revocable, and Suspendab._,. <br /> ENVIRONMENTAL. HEALTH PERMIT SEP;A�E <br /> LIQUID WASTE <br /> ` <br /> App IcaMnish9rebytnade t carry on bu in s in t jurisdictional area of th Joaqu' Local Health District <br /> wBusines ame (DBA �Address <br /> z Owne Address <br /> a <br /> Firm Partners, Addresses and Tel pho a Numbers <br /> CL <br /> Business Telephone No. a Q.� Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title � - <br /> 1 Date <br /> Please check Applicablegory(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r <br /> For July 1, June 30, 19 Disposal Sites J <br /> Description(Make/Yr., Color) �— <br /> Serial No. CAL. License No. _ CAL. ULC;,�e Rencwai 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.S. or R.C.E. No. { <br /> Test Lotion Test Date/Time <br /> 4. I SANITATION PE MIT r <br /> Job Adds ocation —Q <br /> I <br /> Owner Address <br /> 11SEPTIC TAN ❑ CESSPOOL �"CEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW R;--REPAIR <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 ►" i <br /> l <br /> Type Construction Disposal Site i <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 ,' . �¢ ,. - , ti. ., ._.... _ -- - �•_ - -- .:_-', :-. 13, <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, and ules and regu ion of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ElANNUALLY ❑ PER UNIT 13PER SITE ElEACH ElJanuary 1 &Received By January 31 13July 1 &Received Hy Juy <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED i <br /> C[ AMOUNT <br /> FEE Ls L'ti.J <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ] ' <br /> I <br /> OTHER <br /> OTHER <br /> s� < s y <br /> Received by Date Receipt No. Permit No If suancEl Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />