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APPLICATION �i <br /> or Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE _D <br /> J' <br /> Applic herff made to carry oN business in the jurisdictional area of the San Joaquin Lo(,�t Healt,•'Dis"ict –t <br /> yBusiness Name {DBA � c � AddrecsLf-i :� <br /> Owner_ Address — <br /> Firm Pariners, Addresses and Telephone Numbers _ <br /> I <br /> Business Telephone No, �. y Emergency Telephone No. <br /> � <br /> Contractor Licence No. <br /> L Applicants Name (Pr'int) Title Date <br /> Please check Applicable Calego y(1 4) and Fill in the RequirT_TI formation <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 /> f 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 /> •` _ <br /> J A ress/ c o Lo ati n <br /> ob dd <br /> Owner � dAld ress <br /> 5 0 PACKAGE PLANT <br /> ASEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ PaU 'l <br /> ERMANENT ❑ TEMPORARY NEW ❑ REPAIR w OTHER <br /> .5N ❑ CHEMICAL TOILETS For July 1, -Ju e 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/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, and rules and reg" (0-9s of the Sar; Joaqui 4- t <br /> ordinances, District. I <br /> . . <br /> APPLICANT'S SIGNATU Xall <br /> ft\ <br /> FOR DEPARTMENT USE O�f1LY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH J n aVr�1i 1 &Received By Janvary 31 ❑ Juiy i &Received By Jvly 31 <br /> BILLING tj��AINCE $ REMIT <br /> BASE EXPLANATION - DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> IEE <br /> LESS <br /> PRORATION <br /> PLUS <br />{ PENALTY <br /> OTHER <br /> OTHER <br /> G _�_.._------ <br />`- ftFseived 6y - Date Receipt No. Permit No �Isuance Date Mailed Delivered <br /> —.APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES _1601 E.HAZELTON AYE-,P.O.Box 2009 _ STOCKTON,CA.95201 -.--: <br /> PLATE 23 <br />