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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 /> /L 0 ENVIRONMENTAL HEALTH PERMIT SEI'T4GE <br /> "TI LIQUID WASTE <br /> Applica ' s y to car on busines i the iunsdictional area of the an oaquin Local Healt Di tr' <br /> rn Business Name (DBA) Address <br /> i Owner I Address S ` <br /> a <br /> Firm Partners, Addresses and one Numb rs <br /> aBusiness Telephone No. S_ GJ Emergency Telephone No. <br /> Contractor Licence No. -7 7 <br /> L Applicants Name (Print) / Title — Date <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 <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 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time r <br /> 4. X SANITATION PERMI .-.�� <1� �'*�►-�_/.}�"'p� <br /> Job Address/Location n0.3 �� l <br /> Owner 4W 0 �{�/ /V/i Address—/QIsQ � /Vj �js ,— /Q.(j <br /> C1 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> 10 PERMANENT ❑ TEMPORARY ❑ NEW UVREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19_ <br /> Operator Name _ Where Certified N\ <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 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I epared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state law , an and regul tions of the San oaquin Local Health District. <br /> a <br /> APPLICANT'S SIGNATURE X <br /> 412 <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 July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 1 <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss ance Dae Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL- EALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />