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Applications Will Be Processed When Submitted Property Completed. <br /> APPLICATION BeeleTo S> n The Application. <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> nJ ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE Oz77- �qv:96 <br /> Application{Is h reby ma e t carry on busi ess it th Jurisdictional area of the Si Joaquin Local Health District <br /> F Business Name (DBA) N� a! <br /> i Owner <br /> Address I t <br /> Firm Partners, Addresses find T lephone Numbers - Address <br /> , V51C <br /> III. <br /> Business Telephone No.� <br /> Contractor Licence No. - Emergency Telephone No. <br /> a <br /> Applicants Name(Print <br /> Please c k Applicable Title � <br /> Date� <br /> eg ry(1-7) M <br /> andFIII in thee ' 9 <br /> 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. <br /> CapacityCAL. License Renewal No. <br /> Gal., Weights & Measures No. <br /> Equipment Parking Ad ress <br /> 2. ❑ PUMPER D <br /> For July t June 30, 19 <br /> No.of Vehicles Stored <br /> No of Ch Cal Toilets Stored n <br /> 3. ERCOLATION TEST'— <br /> R.S. or R.C.E. Name R.S.or R.C.E:No. <br /> Test Location Test Date/Time ^� — <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address - <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30. 19 <br /> Type Construction Disposal Site L-�Z <br /> r <br /> No. of Units Equipment Storage/Cleaning Location(s) � o <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name <br /> Plant Location Where Certified -!�`•k �i I ��T a jy. <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. 1 2—l(0 Z <br /> ❑ DRY CLEANING,Chemicals Used/AmounVMo. <br /> 1 hereby certify that I have prepare IT application an the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. <br /> APPLICANTS SIGNATURE X Title S�, /CG Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 S Received By July 31 <br /> BILLING REMITTANCE $ REMITDUE <br /> BASE E%PLAN ION DATE DATE REMITTED AMOUNT CHECKED <br /> /� AMOU T <br /> FEE . // ._ l - T <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 76 <br /> lved by Date Receipt No Permit No. bauance Date Mailed Delivered <br /> AWLICANT—RETURN ALL COPIES ENVIRONMENTAL HEALTH PERMIT/SERVICES 16111 E.HAZELTON AVE.,P.O.Bea 2M STOCKTON,CA 115Z01 <br />