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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 /> ENVIRONMENTAL HEALTH PERMIT <br /> "'U 0 WASTE <br /> Application is he by m t ar on si ss e' risdictional area of the San Joa in Local F{�alth District <br /> F Business Name (DBA) n t �r s i <br /> aOwner ---- --- -- dress T'Ce <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> a 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 <br /> r <br /> 4. ❑ SANITATION PERMIT f <br /> Job Address/Location -- _ -- _ <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ 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 <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 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. <br /> APPLICANT'S SIGNATURE X Ti Date <br /> F EP R7QNTVNLY <br /> Fee)3 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 /> r DATE DATEEMITTED AMOUNT <br /> FEE — <br /> i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> cei ed by ateeip Permit No issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONME AL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BOR 2009 STOCKTON,CA 95201 <br />