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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION _ <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT r1S <br /> LIQUID WASTE <br /> Application is hereby ma As to carry on b4si�ness n the jurisdictional area of the San Joaquin Local Health District 1, <br /> rn Business Name (D A) 1q}wCcdL icy+ COn'S r`UL�'w% Address --I bO TJ�O– {2d S2 Glr.vl S'�(-� �`) F <br /> i Owneress <br /> EM 12 <br /> Firm Partners, Addresses and Telephone Numbers—kle,A W zaZs E h7�!• 9.yQ_ 34S <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. T <br /> Applicants Name (Print) arc^^ Title T�h 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 TST 1111.. g <br /> R.S. or R.C.E. Name OtY 14f;-Aw R.S.or R.C.E. No. <br /> Test Location 1 7f Test Date/Time T� 6'L $ J 1P SOt. ui cti„_ <br /> 4. ❑ SANITATION PERMIT 11;11511Y erc <br /> Job Address/Location Q 96v� ii (.lAL;t 0"_ <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/AmounVMo. <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. I 1 <br /> APPLICANT'S SIGNATURE X Title /�G� Date /zol� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑July 1 8 Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY I <br /> OTHER <br /> OTHER <br /> WZ <br /> eceived Oy Date �G Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1641 E.HAZELTON AVE.,P.O.Be.ZOOM STOCKTON,CA 95201 <br />