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Applications Will Be Processed When Submitted Properly Completed. be sure Io sign Ine Application. <br /> APPLICATION ` <br /> (.1'r Non-Transferable, Revocable, and Suspend, <br /> ENVIRONMENTAL HEALTH PERMIT 5EPTAGE <br /> LIQUID WASTE <br /> Applicalionjis.hereb�_VJZ4 <br /> made t car on bu ess in the urisdj t, nal area of the Joaquin Local Health District f .. <br /> H Business Name i A)_ ` `jCt AddressZL —_ <br /> aOwner .?.. Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. -S t _ Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants Name (Print► �L c -1_ �;.t.r�~ Title -ri Date } <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> r'r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r <br /> For July 1, June 30, 19 Disposal Sites <br /> Description (Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licz.se Re,7ewal 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 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test L99altion Test Date/Time <br /> 4. ff SANITATION PERMIT <br /> Job Address/L cation Z-- ]I ?a--I <br /> Owner <br /> Address <br /> ❑ SEPTIC T K ❑ CESSPOOL ❑ LEACHING FIELD EEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW PAIR ❑ OTHER Cl' <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 —r <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. r� <br /> t <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 r and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I a Received By January 31 ❑ July 1 8 Received By Judy 31 <br /> BILLING nEMITTANGE I .y REMIT <br /> BASE EXPLANATION DATE I DATE REMITTED AMOUNTDUE� CHECKED <br /> AMOUNT — <br /> FEE <br /> LESS _� I <br /> PRORATION <br /> PLUS <br /> PENALTY — --------�-- -- i _._..__---- — —_ <br /> _�_ -�--- <br /> OTHEROTHER <br /> I <br /> Received Oy gale Receipt No. _ Yerrml No Issuance Oat Mailed pelivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201 <br />