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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 2 <Jl¢ Z <br /> APPLICATION t 00 << <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicata s_�hereby ade c rry n business in the jurisdictional area of the San J9aqu ocal alth District <br /> rn Business N me (DBA) ►,,Ig , , f Address 2 �O Ian S441� <br /> a Owner .-- 4.r�n-r Address <br /> J Firm Partners, Addresses apid Telephone Numbers <br /> E Business Telephone No. 3) S 2— Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants Name (Print, O lr 1 �L <br /> W 'D)--- Title G t J t[- IEPJG I A1;Ei�Date _ ►1_`_')-Z— <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 o Chemical Toilets Stored <br /> 3. PERCOLATION TE S' q 2 ,_•— �z6�� -- <br /> R.S. or R.C.E. Name N L4 L D R.S. r R.C.E. o. (og 3S <br /> Test Location (,t)Ilt-&AM5 Tz, Date/Time <br /> 4. ❑ SANITATION PERMIT 2_ <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 /> A <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 Title ` 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 /> BILLING REMITTANCE $ <br /> BASE PLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �— --— --- — <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Ri5ceived 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.Boa 2009 STOCKTON,CA 95201 <br />