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'T 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 6EPTAGE <br /> LIQUID WASTE <br /> Applicati Q s h by d carry bus e n the jurisdictional area of the San aqui ocal a Ith Di ict <br /> OF Busin me {DBA) Address r. <br /> 4 Owner Ad ss I <br /> J Firm Partners, Addresses and el phone Numbers <br /> a3 Telephone No. 3� �! Emergency Telephone No. <br /> Contractor Licence No. 30 71Z <br /> Applicants Name (Print) f 1'& Title Date l�" <br /> Please check Applicable Category (1-7) and Fill in the Required Information q <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 0 <br /> For July 1, June 30, 19 Disposal Sites <br /> i <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> a <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored F <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TE$,T <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT /� <br /> Job Addres ocation <br /> 'P ry <br /> Owner Address -! <br /> �SEPTiC TANK ❑ ESSPOOL C:CEACHING FIELD C-SEEPAGE PIT ❑ PACKAGE PLANT <br /> 9-f� ERMANENT ❑ TEMPORARY ©-61EW ❑ 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 prep.ar57 this applica n and that the work will be done in accordance w},tb San Joaquin County <br /> ordinances, state laws, and r s d regulation f e an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X l <br /> it A �IV <br /> . <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 �yed January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED i <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ° V <br /> OTHER <br /> OTHER <br /> 1 ` U� <br /> Received by Date Receipt No. Perm it No Issu nce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> i <br /> I! , <br />