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s <br /> ­Ilt'. _1. 11w IV ue rrucesseu vruen buumltled Properly .;ompleted. be Sure T- Sign The Application. <br /> APPLICATION <br /> (Fo`i"Won-TransferaXh, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SFPTAGC- <br /> LIQUID WASTE <br /> r Application is hereby made t cj rp_jn,busjngss i9 the jun dictional area of the aa1 Joaquin Local Health District <br /> � Business Name (DBA) _�t T1=- �1 ,�� ��It�C�l� 7 t�4I ill t'��le' Address <br /> aOwner _� (�� i T,T�_�— Address —fit Q ��. t ..F1!,L <br /> 7u Firm Partners, Addresses and ele hone Numbers <br /> IL Business Telephone No. Emergency Telephone No.��l/1/\ <br /> Contractor Licence No. ( _ <br /> Applicants Name (Print) — — 1. Title _'�.1�� ��..._. _ Date <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 1 <br /> Description(Make/Yr..Color) <br /> Serial No. CAL. License No. CAL.Liccase 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 <br /> 3. ❑ PERCOLATION TEST C <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Datelrime <br /> 4. ❑ SANITATION PERMIT � <br /> Job Address/ cation C_ F C <br /> Owner Kr`r Address SK NA L. (1 <br /> .SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT C� <br /> ❑ PERMANENT ❑ TEMPORARY 5eNEW ❑ REPAIR ❑ OTHER <br /> S. ❑ 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. Fl., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amounl/Mo. <br /> I hereby certiI have prepared this application and that the work will be done In accordance with San Joaquin County <br /> ordinances, sl laws, nd rules al regulationsfif the an oaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January RecedrB a u ❑ July 18 Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION DATE DATE I TED AMOUNT.DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -g <br /> Received by Date' Receipt No. Permit No. I ua Date Mailed Delivered� ti <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E HAZELTON AVE.,P.O.Boa 2000 STOCKTON. 0S <br />