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. APPLICATION <br /> (`I ��'IVOn-Transferable,Revocable,and Suspendable)`/ SEPT AGF <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is tWreby made tocar on business in the jurisdictional area of th San Joaquin Local Health District <br /> I. f/ / <br /> Business Name (DBA. � � �,� '�- Addres E�/ <br /> Owner Address <br /> rm Partners, Addresses and Telephone Numbers <br /> "usiness Telephone No.__' �-1 7 Emergency Telephone No. <br /> Contractor Licence No. <br /> pplicants Name (Print) �T �y� s//f'l S Title d Date <br /> pease check Applicable Category(1-7)and Fill in the Required Information <br /> vii <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) +^� <br /> -Dr July 1, June 30, 19 Disposal Sites -- - - <br /> �escription(Make/Yr.,Color) <br /> Serial No. CAL. License No. . CAL. License Renewal No. - <br /> Capacity Gal.,Weights&Measures No. - — <br /> quipment Parking Address -- -- <br /> Ill!. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> Jo. of Vehicles Stored — - -- - - - -- <br /> ..Jo. of Chemical Toilets Stored - - - <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. <br /> est,Lin Test Date/Time --- --- I <br /> '%. El SANITATION PERMIT fir/ 0 <br /> Job Address/Location"L//60 <br /> DW Addres <br /> .t/ s <br /> b. SEPTIC TANK ❑ CESSPOOL LEACHING FIELD EPAGE PIT 11 PACKAGE PLANT <br /> L3 PERMANENT ❑ TEMPORARY 0 EW ❑ REPAIR ❑ OTHER -4 <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 C <br /> Type Construction Disposal Site <br /> ilia 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 /> h-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 /> 1 hereby certify that I VVe prepared this application and th t the work will be done in accordant FvjRb San Joaquin County <br /> ordinances, state la n egulatio s f the S Joaq n Local H�al�h District. I r <br /> APPLICANT'S SIGNATURE <br /> +a. ' <br /> FOR DEPARTMENT USE ON6 ; <br /> t <br /> Fee Is Due: ❑ ANNUALLY C] PER UNIT PER SITE ❑ EAt�i. ❑ Ja u y Received By January 31 ❑ July 1 8 Received By July 31 <br /> y REMIT <br /> BASE EXPLANATION BILLIN R IT-fA $ AMOUNT DUE" CHECKED <br /> L� C D 11 v11c7 REMITTEDAMOUNT <br /> FEE <br /> LESS %f <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> Received by Date _----Receipt No ---- Permit No. Issuance Date- Mailed Delivered <br /> eI a COatFS TO- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE-,P.O."-7 - STOCKTON,CA 95201— ^ <br />