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` Applications Will Be processed When Subt.litted Properly Completed. Be Sure To Sign The Application ` Y <br /> APPLICATION <br /> (For Nan-Transfe.able, Revocable, and 5uspendable) <br /> ENViRO MEN''F"AL:FrEALTH PERMIT <br /> e r . LfQ1�11],WeASTE i <br /> Appli ration is hereby mac'Zto carry oln•business in trio jurisdictional aha of the 5ango"aqu n Loc ,l 8'alth'Distridt <br /> B siness Name (DBA) _ _ Addresses <br /> z Owner �p�s ' Adaress <br /> Y Fi m Partners, Addresses and Tel W {P1e97 _ —_ <br /> Bwsiness Telephone No. •t ?t Emergency T lephone No. <br /> Contractor Licence No. I * ���'" • `" i µ ` <br /> Al.plicants Name (Print) _� .. . . ..__�� _M._ _.__.___ Title Date <br /> Please Check Applicable Category (1-7) and Fill In the Required Information ,J <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites - <br /> Description(Make/Y.., Color) <br /> Serial No. --.__ CAL. Utense Na. CAL. License Renewal No. <br /> Capacity _- __ _ Gal.,Weights 'Measures No. <br /> Equipment Parking i,ddress <br /> 2. ❑ PUMPER YARD <br /> c.rr July 1,- )une 30, 19 <br /> *-o of Vehicles StorA <br /> r :. of Chemical Toilets Stored <br /> ❑ PERCOLATION TEST <br /> I-, S. or R.C.E. Name R,S. or R.C.E. No. —� <br /> ,!st Location -_ Test Date/Time . . - <br /> 4, p SANITATION PERMIT W <br /> Job Add resslLocation 'I JA c-33 <br /> Address <br /> C1 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY Ll NEW © REPAIR ❑ OTHER <br /> 5- ❑ CHEMICAL TOILETS For July 1,-June 30, 19 - . . - <br /> Type Construction. _ �_.... _ Disposal Sltct — <br /> t\.o. of Units _ Equipment Storage/Cleaning Location(s) _ — <br /> 6 ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Gperator Name ._ __- _ Where Certified — <br /> P'ant Location. - <br /> Plant Capacity No. Units Served - <br /> ❑ LAUNDRY For July 1,-June 30, 19 <br /> t ZE: ❑ 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 th s application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an rtTtulaons aft San Joaquin Local Health District. <br /> APPLICANT'S SIGH ATURE X 6 - — — <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT_ 11 PER SITE C1 EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ qM L)NT DUE CHECKED <br /> FEE �- DA/E DATE REMITTED AMOUNT <br /> � i 3 "dam <br /> GE55 __...___....— <br /> PRORATION <br /> PLUS --...__.-.-. .. _..._._ <br /> i PENALTY.—._.. --- <br /> OTHER I <br /> OTHER <br /> -- <br /> Received by Dale Receipt N Permrt No. Issuance Date Mailed Delivered <br /> APPLICANT—RL rURN ALL COPIES TO: MIRONMENTAL H 7ALTF: sRMIT/SERVICES 1601 E.HAZELTON A'E.,P.O.Bow 200 STOCKTON.CA 95201 I <br />