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' Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign Thb Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) ` <br /> ENVIRONMENTAL HEALTH PERMIT / <br /> LIQUID WASTE <br /> Application Is h¢r'aby made ar r on business in the jurisdictional area of the Joe Local Health District <br /> Business NameT. i`-�' C �� el Address <br /> wrier I /�t,l� St, <br /> Address <br /> (usiness <br /> rm Partners. Addresses and Telephone Numbers <br /> Telephone No. 4'! Emergency Telephone No. <br /> Contractor Licence No.' ----- 2 <br /> pplicants Name (Print! Title ¢- __. bate _ <br /> lease check Applicable Category.(1-7)and FIII in the-Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> FJuly 1, June 30, 19 Disposal Sites —_— <br /> ascription(Make/Yr,; Color), 1 <br /> Seria! No, CAL, License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> quipment Parking AddraAs <br /> ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> �o. of Vehicles Stored <br /> Jo. of Chemical Toilets Stored -------- <br /> 3. ❑ PERCOLATION TEST <br /> S. or R.C.E. Name - R.S.or R.C.E.No. <br /> est ocation - - ' - Test Date/Time -_.. <br /> SANITATION PERM ` �O �J /n� _- <br /> Jo Address/Loca 'on <br /> ner r Address <br /> SEPTIC TANK ❑ CESSPO LLE_ACHINC},FIELDSEEP.AGE PIT 13 PACKAGE I}LANT u <br /> PERMANENT- - ❑ TEMPORARY Ew ❑ REPAIR ❑ OTHER <br /> ❑ CHEMICAL TOILETS For July 1,-J�30, 19 <br /> ype Construction Disposal Site ..:.._. <br /> o. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> perstor Name - Where Certllled <br /> Plant Capacity No. Units Served __— <br /> ��77 ❑ LAUNDRY For July 1, -June 30, 19 ^—� - <br /> ZE: ❑ Less Than 1,000 Sq. Ft, ❑ More Than 1,000 Sq. Ft. --� - <br /> DRY CLEAN ING,.Chemicals Used/Amount/Mo. <br /> 1 1r1*A4W 23-62. <br /> I hereby certify that 1 have prepa is application and that the work will be done In accordahc�San Joaquin County <br /> ordinances,state laws,and rule egulati s of the San J -in Loca ealth District <br /> tPPLiCANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY ,�•-, <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH ❑ January 1 &Received By January 31 ❑ July 1&Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE - CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> a <br /> FEE <br /> LESS /PRORATION <br /> PLUS <br /> PENALTY" <br /> ' OTHER <br /> OTHER <br /> -3 <br /> v <br /> ' Received by Date Recelpt No. Permit Nosquame a e Malled Deeveredot <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.B 2009 STOCKTON,CA 95201 <br />