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Applications Will Be Processed When Submitted Properly Completed.'Be Sure To Sign The Application: <br /> APPLICATION <br /> )Zr - (For Non-Transferable, Revocable,and Suspendable) a <br /> ENVIRONMENTAL HEALTH PERMIT SERTAGE <br /> LIQUID WASTE <br /> Application i reb made r b siness in the jurisdictional area of the San Joaquin Local Health District <br />.,„Business Nam BA) Address <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No, Emergency Telephone No. <br /> Contractor Licence No. <br /> G •� <br /> L Applicants Name (Print) a Title Date <br /> Please check Applicable Category (1-7) and Fill in?he Required Information W <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r 1 <br /> For July 1, June 30, 19 Disposal Site_s [� <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL.. License Renewal No. t <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> j <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored - <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST E <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. OSANITATION PERMIT <br /> Job Address/Location r <br /> Owner Address <br /> &fSEPTIC TANK ❑ CESSPOOL LEACHING FIELD !!R SEEPAGE PIT 0 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW Q60EPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 71- <br /> Type <br /> Type Construction Disposal Site AV 1 <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 e <br /> Plant Location - - <br /> Plant Capacity No. Unitd-Served <br /> ,7. ❑ LAUNDRY For July 1;-June 30; <br /> SIZE:. ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 1` <br /> I hereby certify that I have prepared this a plication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r nd regul ions of a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> - s <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 1 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT s <br /> FEE <br /> LESS <br /> 'PRORATION } <br /> PLUS <br /> PENALTY <br /> OTHER / r <br /> OTHER <br /> Received by Date Receipt No Permit No. Issuanclibbite Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 i1 <br />