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-Nations Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ' APPLICATION - - - <br /> Y (For Non-Transferable, Revocable,and Suspendable) <br /> 1100 <br /> ENVIRONMENTAL HEALTH PERMIT 5EPTAG£ <br /> r LIQUID WASTE <br /> Applicatjion is hereby made to carry on bus' ess in the jurisdictional area of the an Joaquin Local Health District <br /> F Business Name DBA I -�-� �/�L �tL �C �l T7`f� Address <br /> Q Owner <br /> Address - , <br /> J Firm Partners, Addresses a d Telephone Numbers <br /> M Business Telephone No. t� Emergency Telephone No. (�Yh <br /> 1 Contractor Licence No. 1 <br /> L Applicants Naine (Print) ' - Title 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 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc,lse Renewal No. two <br /> Capacity Gal., Weights & Measures No. =Q <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 Location L Test Date/Time <br /> k4. ❑ SANITATION PE MIT <br /> Job Addre �s �occation <br /> O ,s�lner �,�y�VA-k,> )I-L1 Address <br /> SEPTI ❑ CESSPOOL I ❑ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY' .i `s NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, �June 3Q 19 e . <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> a 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Y� Operator Name ` Where Certified <br /> ., Plant Location Y <br /> Plant Capacity No. Units Served <br /> 1. <br /> 7.'.11 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 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state I ws, rules and r u io s-of f EI n quin Local Health District. <br /> ( ' APPLICANT'S SIGNATURE X <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 /> i. <br /> L REMIT <br /> BILLING REMITTANCE - <br /> k. BASE EXPLANATION $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS i /� � * x <br /> PRORATION { <br /> PLUS 3 5'�� ' <br /> PENALTY <br /> OTHER ¢ <br /> OTHER F "" <br /> 2,zs- _ <br /> 'Received b Date 4 Receipt No Permit No. Issuance Date Mailed Delivered <br /> W - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> ;}7. <br />