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Applications Will Be Processed When Submitted Properly Completed.:tseure r 01W..APPLICATIONCyO(For Non-Transferable;.Revocable,and Sus dable) ;SEPT7AGE i <br /> 4 ENVIRONMENTAL HEALTH P MIT {_ <br /> LIQUID WASTE <br /> t Application is hereb made to carry on business in thelurisdictional area of the San Joaquin Local Health District.. �SZo <br /> R Address ....• <br /> m Business Name (DBA) APPIM <br /> Address <br /> 4 Owner L., <br /> Yj Firm Partners, Addresses and Telephone Numbers Emergency Telephone.No - <br />` a Business Telephone No. a -. <br /> a <br /> Contractor Licence No. I�A1��<<r ;1� ,, Date I,• 9 <br /> Title,' <br /> L Applicants Name (Print) <br /> f l lyy,� ,.'� f , j•T <br /> t 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 /> r Description(Make/Yr.,Color) ,� h CAL. License Renewal No. <br /> Serial No. GAL. License No.� <br /> Capacity Gal,,-Weights & Measures <br /> Equipment Parking Address <br /> F 2. ❑ PUMPER YARD <br /> For July 1, June'30„19 <br /> -No. of Vehicles Stored <br /> No. of Chemical Toilets Stored j ; <br /> 3. ❑ PERCOLATION TEST R.S. or”R.G.E.Nod a't�,T� <br /> 1... , <br /> f R.S. or R.G.E.Name Test Date/Time <br /> + <br /> Test Location y <br /> 4. SANITATION PERMIT [ <br /> Job Address/Location <br /> Owner Address <br /> EPAGE PIT ❑ PACKAGE PLANT <br /> ❑ C 'LEACHIN <br /> �+ ❑ SEPTIC TANK <br /> CESSPOOL G FIELD C�9E ❑ OTHER <br /> B'PERD/IANENT 13 TEMPORARY ❑ NEW _ Er-REPAIR <br /> r 5. ❑ CHEMICAL-TOIETS For July 1, -June 30, 19 4 <br /> ...t 4 4,,"1 s„—-- .-n- — t_.,Ojsposal.Site _•--_-'•,�._..._ -- -�-. ,,T._ -.. c,.....-- 1 <br /> Type Construction 4-- -^^�� <br /> � Equipment Storage/Gleaning Location(s) <br /> No. of Units <br /> 6, 11 PACKAGE TREATMENT PLANT For July i, -June 30, 19 tom;, li�1N.N--Wjier-ee Certified <br /> Operator Name <br /> Plant Location _ _ %7% T � No. Units,Served <br /> Plant Capacity <br /> I 7. z� LAUNDRY«For July,1,--June 30, 19 ^r R ' <br /> ❑ More Than i;OOOZq: Ft.^ * ; <br /> Si�ZE: ❑-Less Than 1,x00 Sq. <br /> ❑'DRy CLEANING, Chemicals Used/Amou Wo. a <br /> Ikcatian and th the work will,be done in accordance with San Joaquin County- <br /> red I hereby certify thAtU�iv�eepathis app <br /> ordinances, state tes and regulati of the S aqui I eaItl7M1Ditrict.APPLICANT'S SIGNATUREX <br /> a <br /> it <br /> b ` FOR DEPARTMENT USE ONLY <br /> `�- . <br /> Fee IS DUe:-❑ ANNUALLY ❑ PER UNIT El PER SITE ,❑ EACH ,❑ January 1 &Received By January 31 ❑ July i &ReceiveRdEBM1ITuE 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED: ' <br /> £ l r BASE EXPLANATION DATE - DATE REMITTED - AMOUNT, <br /> t FEE`: F <br /> LESS •;'�^ ♦ r. ^ Z 7 61 i <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> �. 'OTHER <br /> OTHER <br /> Dale x Receipt <br /> ssuanc Da a Mailed Delivered <br /> Received by No. Permi No 1601 E.HAZELTON A .Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />