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Applications Will Be Processed WhenSubmittedProperly Completed. Be Sure To Sign The Application. ' <br /> *. APPLICATION .. " .., . <br /> r (For Non-Transferable, Revocable,and Suspendable) SEP�TAGEit <br /> � ✓ ENVIRONMENTAL'HEALTH PERMIT " <br /> LIQUID WASTE <br /> e i <br /> Applica ion is ereby mad to caron business in the jurisdictional area of San oaquin Local Health District <br /> yBusiness Name (DBA) �.. - Address. WM 145aD <br /> a Owner <br /> Address �` <br /> Firm Partners, Addresses and Telephone Numbers <br /> 6. Business Telephone No..— y��-42— Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants Name (Print) 41STitle Date F ) <br /> 4 Please check Applicable Category (1-7) and gill in the Required'Information06 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) { <br /> For July 1, -June 30,:19= - - Disposal-Sites = - <br /> Description(Make/Yr.. Color) <br /> t Serial No. CAL. License No. CAL. License Renewal No. <br /> I Capacity Gal., Weights &Measures No. t <br /> Equipment Parking Address F <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 /> i <br /> - Tes cation. Test Date/Time <br /> 4. SANITATION PERMIT «-,.. <br /> j Job Add r ss/Loc tion r�G �© +. <br /> Addr <br /> OwnerY e s r <br /> C1SEPTIC TANK ❑ CESSPOOL y ��EACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT _ <br /> I, .PERMANENT 11TEMPORARY 13NEW,•;"., ;- REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19' ,r, <br /> Type Construction Disposal Site r' <br /> No. of Units +a Equipment Storage/Cleaning Locat_ion(s) " <br /> 6. ❑ PACKAGE TREATMENT;PLANT�,,For July 1 `Julie 30, 19 _ y# <br /> Operator Name.. - Where Certified _ + <br /> j Y <br /> Plant Locationfy <br /> Plant Capacity No. Units Served r`0: <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,' ❑ More Thaii,1 000 Sq. Ft. <br /> ❑ DPjy CLEANING,Chemicals,Used/Amount/MO. ^ " <br /> OingblMtel OrlFL'eA6Bd ` .�� <br /> ngesubj etto �orece,r,'5ccthe�ot.owing: Icerti:yyfh,�r+nfhepefoTnan;,c ,theworkfarwh}chthispermitisissued,lShillnotemplayanyper <br /> in such snasuler as fo become subj,et to workman's c'.ohtpensatlr,.a>ks of i:altforn.� <br /> COnUmtor's Ailing or sub-cwttrac' = F I <br /> e la r�enatuln ee,rtsf— IMP f-Howing: ;certify that in Etre pertorrnance of the work far which this permit is issued,I sha>I <br /> Y f>ersatls subject#a workman's compensation laws of Califomia." ' <br /> i I hereby certify that I ha prepaid this"application and th he rK wilt be done in accordance with Soman Joaquin County <br /> I ordinances, state laws, . 'and r ulations e SJo Lin ocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> , <br /> } <br /> 3 . . <br /> FOR-DEPARTMENT USE ONLY <br /> s _ 7 ( .R <br /> Fee Is Due: ❑ ANNUALLY' ❑ PER UNIT' ❑ PER SITE — ❑ EACH ❑ January 1 &Received By-January 31 ❑ July 1 &Received By July 31 <br /> a ' BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED? <br /> T- DATE - DATE -_ REMITTED r� AMOUNT ✓`� <br /> FEES t JfAy s <br /> LESS 1 } <br /> PRORATION j E 4 <br /> i <br /> PLUS­!, <br /> t t t <br /> PENALTY .yy P <br /> OTHEFi� <br /> - C f <br /> Received by _ ;: Date Receipt No. Permit No. t F I suan. Date., -Mailed Delivered-,J;;V j <br /> r':: APPLECANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES r`""�°' 1601 E.'HAZELTON AVE.,P.O.:Box 2009"`''��=STOCKTON,CA 9520. - . <br />