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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE ^ / <br /> pplicati�*;is hereb ade to c r n business in the jurisdictional area of the San Joaqui Local aIt h District I K / � i✓ ;7 <br /> A p 1 <br /> y Business N me (DBA)KLA t Q jy LJe Ct U m Address l ) �OVi� <br /> i Owner -Id r - - Address <br /> u Firm Partners, Addresses a d Telephone Numbers — - <br /> 'a Business Telephone No. �2 0 19 3 1 ' I Z__. Emergency Telephone No. <br /> Contractor Licence No. -7 <br /> a Applicants Name (Print) OtiJ '� (� E L' U Title �-l IL ENCS I� ate <br /> -Please check Applicable Category (1-7) and Fill in the Required Information <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 /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored i — <br /> 3. ,(PERCOLATION TEST p --T / <br /> R.S. or R.C.E. Name V oIJA L-I L �� R.S. o`R.C.E.No. & -S _ <br /> Test Location I t L. MTest Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> 2-1 -q"L <br /> Job Address/Location --- <br /> Owner Address - <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, - June 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. <br /> APPLICANT'S SIGNATURE X v Title/ �y t Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE F�XPLANATION BILLING REMITTANCE f AMOUNT OUE CHECKED <br /> DATE DATE REMITTED AMOUNT_ <br /> FEE <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> tr <br /> Received by Date Receipt No Permit No. Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.box 2009 STOCKTON.CA 95201— <br /> E X t4i9,'(-r <br /> 5201Exr4i9,'1-r ll D-31I <br />