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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 /> rV IAS tm. <br /> Tt..�Application i�s 6 e6yta� to'cacry on busin1 ssi ejuristlictiona San Joaquin Local e IEIiDistr tf — d <br /> s �n Business Name (DBA d ss <br /> ? Owner PSN4A _ C n' Address 0 CA <br /> Firm Partners, dresses and Telephone Number Or <br /> aBusiness Telephone No. 3 0 Emergency Telephone No. Q �/ <br /> Contractor Licence No. T <br /> � <br /> I Applicants Name (Print) Fuer-At^ � �- Title N Date 0 <br /> %V 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 P -� <br /> 2. ❑ PUMPER YARD a 07- <br /> For <br /> 7 For July 1, June 30, 19 <br /> No. of Vehicles Stored — <br /> No Chemical Toilets Stored — 4 ✓ <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 /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner — Address— <br /> E] 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 /> hereby certify that I have preparedeTmapplication and that t work will be done in accordance with San Joaquin County <br /> ordinances, state laws,#Zd rules and gulationsSan Joa in Local Health District. <br /> a <br /> APPLICANT'S SIGNATURE X <br /> 1 <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 EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> .2411 <br /> FEE (!� Z / ) f U )4/V U iy. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> M 0 _;�o <br /> ReceTtytrby 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 />