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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 SETAGE <br /> .e LIQUID WASTE <br /> Applicat,ii,,ft' her9bpX to car on business in the'urisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA) 4 ® /C [JlCE Address d 5 S <br /> 4 Owner Address,17a5" 5, � �/ r� �9 <br /> 1 Firm Partners, Addresses and Telephone_Numbers <br /> i <br /> aBusiness Telephone No. ��J ' �,�� Emergency Telephone No. <br /> Contractor Licence No. 3 <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fil in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites i <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 I <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name I .. R.S. or R.C.E. No. <br /> Test Location t Test Date/Time VVV <br /> 4. SANITATION PERMIT' <br /> Job Address/Location <br /> Owner 4 _ � (Address <br /> f' <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY 1:1NEW 9REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, '`June 30, 19 <br /> Type Constructionr �•� Disposal Site <br /> " � 1 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name # i 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-17000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have repared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state la , an rules and regulations o the;San J;Vauin Local Health District. <br /> APPLICANT'S SIGN TURF <br /> FOR DEPARTMENT USE ONLY ' <br /> Fee Is Due: ❑ ANNUALLY © PER UNIT '❑.PER SITE 0 EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE �P/f7Y1/ „S r GG <br /> Jam , <br /> LESS r <br /> PRORATIONPLUS <br /> ; <br /> PENALTY <br /> OTHER !' <br /> OTHER <br /> a I�1131 <br /> Received by Date Receipt No, Permit No Issu rice btaie Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 25201 I' <br />