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G MP ncaTT ns willtseProcessedWhen SubmittedProperly Completed. Be Sure To Sign The Application. {: r <br /> 4 APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> MQUIO WASTE <br /> Application is by deo arty on usi s in th jurisdictional area of the San Joaquin Local Health District <br /> F Business NarTti SA P yaI s � '� -0� Address <br /> Owner <br /> wner 1 <br /> a Address <br /> J Firm Partners, Addresses and Tel hon Nu b r _ <br /> M Business Telephone No. g Emergency Telephone No, 4. <br /> Contractor Licence No. <br /> s Applicants Name (Print) a r"f 40-CE 0 o Date <br /> Title fl 4 <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICI.9) <br /> For July 1, June 30, 19 t Disposal Sites _ <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. AL. 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 Fis. o E. No. <br /> Te ovation Test U to/Time <br /> 4. SANITATION PERMIT � ff <br /> Job Addressocation /�"r <br /> Owner 12.to Addrt <br /> ❑ SEPTIC TAA CESSPOOL LEACHING FIELD EEPAGE PIT 11.,PACKAG.S PLANT,( <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAlk OTHER r r+� X �'� Mr�tCfL f,�Q lb) - <br /> 5. ❑ CHEMICAL TOILETS For July 1, -'June 30, 9 �J <br /> Type Construction sposal Sit <br /> No. of Units Equipmen St age/Cleaning Location(s) # <br /> 6. ❑ PACKAGE TREATMENT PLANT For July , -June 30, 11) _ d <br /> Operator Name r <br /> - Wher ertified <br /> Plant Location _ <br /> Plant Capacity { <br /> p ty _ No. Unify,erved <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. FL, 13 'More Than 1,0 S Ft, <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> " t <br /> I hereby certify that I have pre r d IN plicati a d that t e work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule a d r tions of the Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X _ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH' ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jury 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUN <br /> FEE + <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r <br /> Received by - Date Receipt No. Permit No. Issuance 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 />