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w Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheAppneatlon. _ <br /> .•'" APPLICATION <br /> '�"'• (For Non-Transferable,Revocable, and Suspendable) <br /> ..>. 5E PTAG E � <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Jooauin Loc' %H a U 'strict <br /> yr, Business Name [DBA (# Address�1 <br /> a Owner - <br /> Address <br /> Firm Partners, Addresses a d Tele h e umbers <br /> a — fc9r- Emergency Telephone No. { <br /> 4 Business Telephone No. I <br /> Contractor Licence No. <br /> Date <br /> Applicants Name (Print) t Title <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 . I <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CRL. LicCnse Renewal No. <br /> Capacity Gal., Weights & Measures No. I <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ! f <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored x <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. ff SANITATION PERMIT f I <br /> Job Address/Location �va or ` 7 <br /> t Address <br /> Owner _ ❑ PACKAGE PLANT *� ' <br /> EfSEPTIC TANK ❑ CESSPOOL EfLEACHING FIELD ❑ SEEPAGE PIT ❑ OTHER <br /> 0 PERMANENT El TEMPORARY IrNEW 11 REPAIR p <br /> 5. ❑ CHEMICAL TOILETS For July 1,- June 30, 19 - Is-\ 'I <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) 1 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19.. <br /> Where Certified <br /> Operator Name <br /> 4 <br /> Plant Location C <br /> Plant Capacity <br /> 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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> R ordinances, state laws; and r es and re ion of the S aquin Local Health District. <br /> APPLICANT'S SIGNATURE <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 Ju1y 31 } . <br /> REMIT' <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EAPLANATION <br /> t DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS — <br /> PENALTY <br /> OTHER r ... • ` <br /> OTHER + - <br /> Permit No. Issuance Date Mailed Delivered 'S <br /> ' ReCved`Gr- to Receipt No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 45201- ` <br />