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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ` ,,•or Non-Transferable, Revocable,and Suspend&. j <br /> ENVIRONMENTAL HEALTH PERMIT SEATAGE <br /> LIQUID WASTE <br /> Application-+s­hereby made to carry on business in the jurisdictional area of the.San Joaquin Local Health District <br /> Business Name (DBA) r::i 3:... 1: d rf <br /> F Address <br /> 17-4AddressAddress <br /> P Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. �r = Emergency Telephone No. <br /> Contractor Licence NO. F <br /> FL Applicants Name (Print) �.y r ` t` : 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, GAL. 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.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location 41 <br /> X . :��'r �= <br /> Owner -'. •r.` -?f=`r s , ,E. , } Address . <br /> ❑"SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ,Ea PERMANENT ❑ TEMPORARY ;-❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction -Disposal,.Site <br /> k No. of Units Equipment StorageA;,leaning Location(s) <br /> I^ 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 application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, ancrWles and regulations of the San.Joaquin.Local Health District- <br /> APPLICANT'S SIGNATURE <br /> 1 , <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 Juty 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE - DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. PerAit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BOK 2009 STOCKTON,CA 95201 <br />