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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION -a <br /> (OWNon-Transferable, Revocable, and Suspendable).4w, I <br /> SEPT GE <br /> I Z/ ENVIRONMENTAL HEALTH PERMIT �} <br /> LIQUID WASTE -0 <br /> ? ``Applic he r,made t i carry OR business in the jurisdictional area of the San Joaquin Lo(�w Healt 1Ji trio j r <br /> Business Name (DBAf <br /> vner 1 �rimy _ Address_ --- — <br /> m Partners, Addresses and Telephone Numbers <br /> Iusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. �s <br /> )plicants Name (Print) Title __.____ Date <br /> —ease check Applicable Catego (1 ) and Fill in the Requir Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> r July 1, June 30, 19 Disposal Sites <br /> !scription(Make/Yr., Color) <br /> Serial No. CAL. License No. ` CAL. License Renewal No. <br /> r'3pacity Gal., Weights & Measures No. _ _— <br /> luipment Parking Address <br /> r ❑ PUMPER YARD r v <br /> For July 1, - June 30, 19 <br /> �. of Vehicles Stored <br /> ��. of Chemical Toilets Stored_ <br /> 3. ❑ PERCOLATION TEST S. or R.C.E. Name R.S.or R.C.E.No. <br /> est Location f Test Date/Time. <br /> 4 ❑ SANITATION PERMIT ( 3 <br /> Job Address/Location — � -_-__ ro <br /> Nner dress <br /> s-oSEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARYNEW ❑ REPAIR f-_-,`❑ OTHER <br /> ❑ CHEMICAL TOILETS For July 1,-J e 30, 19 " <br /> ipe Construction Disposal Site _ <br /> No. of Units Equipment Storage/Cleaning Location(s)7, <br /> G ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> aerator Name Where Certified <br /> "ant Location <br /> Plant Capacity _ i .No. Units Served <br /> ❑ LAUNDRY For July 1, -June 30, 19 <br /> —ZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 4, <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 withilIan,Joaquin County <br /> ordinances, state laws, and rules and regu ons'of the Sawn Joaqui ocal Health District. t <br /> j { <br /> APPLICANT'S SIG . X <br /> TFOR DEPARTMENT USE O LY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH Jan ar 1 &Received lay January 31 July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING ANCE $ AMOUNT DUE CHECKED <br /> TDATE ATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> T PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> T <br /> OTHER <br /> `7 c�` 4 <br /> Y/ LY <br /> � Received by Date Receipt No. Permit No. Issuance 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 />