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Applications Will Be P ed When Submitted Properly Completed. Beo Sign The Application. <br /> APPLICATION <br /> ` (For Non-Transferable, Revocable,and Suspendable) <br /> * ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is,hereby made to carry on business in the jurisdictional area of the San Joaquin;,Local Health District <br /> OF Business Name (DBA) Address <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L 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 /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner 'r' Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ I-I&CHING 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 /> amµ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with SanJoaquin County <br /> ordinances, state laws. <br /> [[ C" <br /> APPLICANT'S SIGNATURE X Title {` `U� Date <br /> FO DEPARTMENT USE ONLY <br /> �---rr - -} <br /> -- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑'PER SITE u EACH ❑ January 1 &Received By January 31 0 July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> �y — <br /> FEE J� .3 � /� M- -5 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date No. Permit No. 1 ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: peceipt <br /> NMENTAL HEALTH PERMIT/SERVICES 1601 ETON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />