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APPLICATION <br /> i <br /> rur Non-Transferable, Revocable, and Suspendabley- <br /> { 5EPTP.GE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LlQtild WASTE <br /> Application is hereb�ade to carry on b rtes in the juris fictional area of th; J uin Locai,H,e District, <br /> � <br /> ### Lc", r > Address <br /> .n Business Name (DBA) <br /> Address <br /> z Owner <br /> !, {irm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> L-.3usiness Telephone No. <br /> -j Contractor Licence No. + ^�" <br /> .: = s `.. Title Date <br /> rapplicants Name (Print) <br /> elease check Applicable Category (1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> ar July 1, June 30, 19 Disposal Sites <br /> r-7escription(Make/Yr„ Color) CAL. License Renewal No. <br /> serial No. CAL, License No. <br /> Capacity Gal., Weights & Measures No. <br /> Fz7quipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> TFor July 1, June 30, 19 <br /> r-No. of Vehicles Stored <br /> y No. of Chemical Toilets Stored <br /> ±3: ❑ PERCOLATION TEST R.S.or R.C.E. No. <br /> S. or R.C.E, Name <br /> I Test Date/Time <br /> est Location <br /> 4. SANITATION PERMIT x^h i <br /> Job Address/ ocation <br /> Owner . . 'r.f Address <br /> { ❑ SEPTIC TANK ❑ CESSPOOL LLEACHING,FIELD ;SEEPAGE PIT' ❑ PACKAGE PLANT <br /> 13 TEMPORARY <br /> ❑ NEW WREPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> FType Construction - Disposal Site <br /> No. of UnitsEquipment Storage/Cleaning Location(s) <br /> i 5, 11PACKAGE TREATMENT PLANT For July,1;-June 30, 19 where Certified <br /> Operator Name <br /> -_Plant Location <br /> Plant Capacity No. Units Served <br /> �7. C1 LAUNDRY For July 1; -June 30,19 <br /> tSIZE: ❑ 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 and that the work will be done in accordance with San Joaquin County . <br /> �a ordinances, state laws'and rules an _,(ejulatio a'.t"San Joaquin Local Health District. <br /> air <br /> APPLICANT'S SIGNATURE X01 <br /> N.= <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ElJuly 1 &Received. <br /> t3y July 31 <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE...- - DATE .... REMITTED AMOUNT <br /> f <br /> FEE <br /> i! LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER4d4 <br /> �I I su a Date ailed Delive <br /> Received by Date Receipt No ermit No: .r <br /> ! 1601 E.HAZELTON AVE.,P.O.BOK 2009 STOCKTON,CA 45201 <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERRMITISERVICES <br />