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Application is ere y d to/c'° rry on bus' es d'i <br /> the jurisc an Joaquin Local eat krict <br />; 49 <br /> Business Name ( A) <br /> ,!! <br /> E Owner i Address. <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. Aency Telephone No. <br /> Contractor Licence No. <br /> Title ���`� Date ) <br /> LApplicants Name (Print) - — r <br /> Please check Applicable Category ( -7)and Fill in the Required In rmation I <br /> 1. ❑ PUMPER VEHICLE PERMIT.REGISTRATION (FOR EACH VEHICLE) <br /> a <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CRL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. ~ <br /> Equipment Parking Address _ g <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored Q <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E.No. m <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location ! 7 <br /> A <br /> Owner Addre ' .� <br /> SEPTIC TANK CESSPOOL LEACHING FIELD SEEPAGE PIT PACKAGE PLANT <br /> ❑ OTHER <br /> PERMANENT ❑ TEMPORARY EW ❑ REPAIR <br /> 5. 11CHEMICAL TOILETS For July 1, -Ju 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 L Where Certified <br /> Plant Location <br /> . Units Served <br /> Plant Capacity No <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, and rut and regulations of the San Joa in Local Health District. <br /> APPLICANT'S SIGNATURE. <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 <br /> REMIT <br /> - BASE ZXPLANATIONREMITTANCE $ AMOUNT DUE CHECKED ; <br /> DATE REMITTED- AMOUNT <br /> FEE <br /> LESS 1 <br /> PRORATION PLUSPENALTY <br /> OTHER <br /> ­�:t___ <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivere <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> 7 <br />