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..Pyuco••o,u ..,,. de rrocesxo Wnen auommed Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ` so(For Non-Transferable, Revocable, and Suspend1154) IF PT/�C"= <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is her made to car{y b4siness in}�e jurisdictional area of t: San Joaquin Loc Health District <br /> i Business Name (DBA) " 4 r i�1)—it� Address r @jui: 1 r7 5' il) c'liCi'L(.� <br /> i Owner <br /> Address <br /> 0 Firm Partners, Addresses and Title In Numbers <br /> 'A Business Telephone No. --- <br /> a Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) yo t^ Title Date _7-aft%'416( 1 <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) i A <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 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 G <br /> Job Address/Location_ wsi <br /> Owner a-11 L TxJ 1'12,1:1 h.�' ' _AC�_"Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL IkLEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> IRPERMANENT ❑ TEMPORARY ❑ NEW (i7 REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site 1 <br /> n <br /> No. of Units Equipment Storage/Cleaning Location(:) _ <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 -� - – - —d <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 /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules a Utati/ :sof thpSa'n�Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> r �0, <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 d ReceivM By July 31 <br /> $BASE EXPLANATION <br /> BILLING REMITTANCE REMIT DATE DATE REMITTED AMOUNT DUE CHECKEDAMOUNT <br /> FEE is r ( / O <br /> LESS Y <br /> PRORATION <br /> PLUS — <br /> PENALTY <br /> OTHER Ir j <br /> OTHER <br /> r <br /> Racened by --- —Dale ------ Receipt No. PermB No. �� <br /> la ua11ce Oe a Mailed waratl <br /> APPLICANT—RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMIT/SERVICES 1901 E.HAZELTON AVE P.O.Bot 200e STOCKTON,CA 19VI-- <br />