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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. T <br /> APPLICATION <br /> ' (For Non-Transferable, Revocable, and Suspendable) �h4AVAIGIECU604%Z� <br /> ENVIRONMENTAL HEALTH PERMIT , <br /> {: LIQUID WASTE <br /> a <br /> Application is hereby ma a to carry on busin s in th ju isdictional area of the San6oaquiq Local Health bisrict <br /> OF <br /> Name (DBA) - L Address <br /> aOwner iL" � Address <br /> k 0 Firm Partners, Addresses a Telephone Numbers <br /> i a Business Telephone No. <br /> a .Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants,Name_-(Pnnt)-L-1 T�t(��, � Title ate <br /> Please check Applicable Category (1-7)and Fill in the Required Information g` <br />' 1--❑ PUMPER,VEHICLE,PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> .11 . <br /> For July 1, r June 30, 19ti ' Disposal Sites <br /> Descriptiori(Make/Yr., Color) <br /> Serial No. <br /> CAL. License No. - -; CAL. Lic;,nse Renewal No. <br /> Gal.;"Weights'&'Nleasures`NO---" <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored- - r <br /> No. of Chemical_Toilets Stored r - ' �, <br /> 3. ❑ PERCOLATION TEST 3 k } <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. s .i <br /> Test Location Test Date/Tim <br /> e <br /> 4. ❑ SANITATION PE MlI1T <br /> Job Address/LocationI Owner 1 <br /> Address - ' <br />'- 9' <br /> SEPTIC TANK 11 CESSPOOL LEACHING FIELD ! <br /> SEEPAGE PIT ❑ PACKAGE PLAN - r <br /> PERMANENT ❑ TEMPORARY. _- NEW.. =" .- „�'`❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 t <br /> Type Construction r ± V t <br /> Disposal Site - } <br /> No. of Units Equipment Storage/Cleaning Loc' <br /> tion(s) <br /> 6. ❑ PACKAGE TREATMENTiPLANT For July 1, -June 30, 19 <br /> Operator Name t # ♦1 <br /> . "' - � Where Certified <br /> Plant. ocation., <br /> Plant-Capacity `.J No. Units Served <br /> 7 ❑ <br /> LAUNDRY .For July 1, -June-30,-19 <br /> SIZE, Less Than 1,000 Sq. FL, <br /> More Than 1,000 Sq- <br />-�,oRY;CLEANING, Chemicals Used/Amount/Mo. <br /> �+ Hfiiir9ow�iatorticsBBedagent'asignaturecerttftesthefeltowing:1 certify that ithe performanceoftheworkforwhichthis permit lshaftnotem !a <br /> In such manner as to become subject to workman's compensation laws of'CaIifDrnja.,, , i p e p-yanyperson <br /> Contractor's hiring os sup-comraetino.,sipnatme cor.':r;ns•the"olluwi I cernfy that in thef <br /> @mplay persons subject to workman's compensation.taws of I._'ifomia." performance of the Work for which this permit is issued`i shall {� <br /> 'I hereby:certify I have prepared-t is application d that the work will be done in accordance with Saloaquin,County <br /> � ) ordinances, sta ' laws, d rules nd r ulatiqVS o th an J uin ocal Health District. <br /> APPLICANT'S SIGNATURE X � '� �'•�, ,d a " <br /> t i <br /> t ¢ s FOR DEPARTMENT USE ONLY {E " <br /> f i �r <br /> Fee Is Due: 11 ANNUALLY 1 PER UNIT ❑ PER SITE ❑ EACH El January i &Received By January 31 El July 1 &Rec#s'lued By July 31 <br /> {#{ BILLING REMITTANC f v REMIT s <br /> -t BASE EXPLANATION $ - <br /> DATE pqT AMOUNT DUE ICHECKED <br /> MfT�TED ; <br /> -�.. ✓.r .i y <- - .. AMOUNT <br /> FEE <br /> L9S^J <br /> PRORATION <br /> PLUS } i <br /> PENALTY <br /> OCHER <br /> 3 <br /> OTHER <br /> r <br /> Received by Date Recei f No, <br /> + Issuance Date fMailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,.P.O.apx.2009 $TOCKTON,CA 95201 <br /> t <br />