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Applications .Wil! Be Processed When Submitted Properly compietea. <br />- APPLICATION <br />,,,.,or Non -Transferable, Revocable, and Suspend 8L - SEPTAPE <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />�` Applica n I her y made to car+)y usmess In �th .unsdictional area of t San Joaquin.Local Health District <br />N Business Name ('DBA) <br />��i� Address �.>�. <br />Address <br />z Owner <br />4 <br />1 Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br />aBusiness Telephone No. <br />Contractor Licence No. _ t-s7liv.�T/)? Date L, 72z Fe) ' <br />a ants Name Print) Title _� <br />Applicants ( <br />Please check Applicable Category (1 -7 . <br />and Fill the Required Information <br />) <br />1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />For'July 1, June 30, 19 Disposal Sites <br />Description (Make/Yr., Color) <br />� '� CAL. License No. CAL. LiRenewal1se Renewal No. <br />Serial No. <br />Capacity - Gal., Weights & Measures No. <br />a v <br />Equipment Parking Address <br />.2.. ❑ PUMPER YARD <br />For July 1,_, June 30, 19 <br />No. of Vehicles Stored Y <br />No. of Chemical Toilets Stored <br />3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br />R S r R C E Name <br />Test Date/Time <br />TestLocation <br />4. }isl+ SANITATION PERMIT 1 . <br />F Job Addressocation <br />owner Address <br />�SEPTIC TANK 11CESSPOOL''} ` ❑NEW 'K LEACHING FIELD WSEEPAGE PIT ❑ PACKAGE PLANT <br />l <br />Ir REPAIRNTHER <br />❑ <br />PERMANENT TEMPORARY <br />5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Construction Disposal Site <br />fi <br />No. of Units • Equipment Storage/Cleaning Location(s) <br />6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 Where Certified <br />` 0perator Name <br />Plant Location <br />No. Units Served <br />Plant Capacity r _ <br />7. ❑ 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 l'have prepared this application <br />ordinances, state laws, and rules and regulation oft/ <br />APPLICANT'S SIGNATUREX `. <br />Fee Is Due: ❑ ANNUALLY <br />BASE <br />.. .FEE tea/ <br />LESS <br />PRORATION <br />PLUS - <br />PENALTY <br />OTHER <br />OTHER <br />that the work will be done in accordance with San Joaquin County <br />i Joaquin Local Health District. <br />-*DR DEPARTMENT USE ONLY <br />- ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & Received By Ja. <br />BILLING REMITTANCE , $ <br />EXPLANATION <br />DATE �. DATE" REMITTED' <br />11 C)g� X31 <br />Q <br />cx <br />uary 31 ❑ July 1 & Received By July 31 <br />REMIT <br />AMOUNT DUE CHECKED <br />AMOUNT <br />it, <br />ceiue8 by Date Receipt No. Permit No. Issuance ua r <br />1641 E. HAZELTON AVE.,P.O. Box 2009 STOCKTON, CA 85201 <br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT lSERVICES - - - <br />• r <br />