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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSign TheAppllcaucin. <br /> APPL.tCATIDN <br /> (For Non-Transferable,Revocable, and Suspendable) SEPT AGE <br /> ENVIRONMENTAL HEALTH,PERMIT <br />! LIQUID WASTE <br /> Appl ication is eby made t arty on pus' ess in the jurisdictional area of the I an aqui Lo ealth District, <br /> y Business Name A) <br /> Address— � �' <br /> 27 <br /> aOwner_ (.. =� <br /> 9 Firm Partners. Addresses and Telephone Numbers ' <br /> aBusiness Telephone Na. r Emergency Telephone No. ,>A <br /> -JContractor Licence No. - n -� �] <br /> Date <br /> Applicants Name (Print) Title �� - <br /> Please check Applicable Category (1-7) and Fill in the Required Information ,• ;�, I.q1b ti <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30,19 Disposal Sites <br /> Description(Make/Yr., Color) i <br /> Serial No. CAL, License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No, <br /> Equipment Parking Address j <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> t <br /> No. of Chemical Toilets Stored ) <br /> i 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or.R.C.E. No. <br /> Test Location ; ' r - ..Test Date/Time <br /> 4. VSANITATION PERMIT <br /> Job Address/ c tion ..77 € <br /> Owner Address. <br /> SEPTIC TANK ❑ CESSPOOL E CHINGFAEL -- ❑ SEEPAGE PIT PACKAGE PLANT <br /> C1 PERMANENT 11 TEMPORARY _ �IPVm <br /> EPAiROTHER WA �1 �� �� *--10 <br /> 5. ❑ CHEMICAL TOILETS For July 1,�-June 30, 19 <br /> Type Construction Disposal Sit <br /> No, of Units Equipment Storage/Clearing;Location(s) I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30 $ <br /> s� Where Certified <br /> Operator Name <br /> Plant Location " <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: 11 Less Than 1,000 Sq. Ft., ❑ More Than 1,00 5q. Ft. .� <br /> 11 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Itomeowner prlicensed agent's 1r}grtiitur9GOKrt?P.St3tS!!{4`1+f1{±�"tcerttf�r'�"'^thr;Aerf"!r re oftl;n�,rer<sfor�:�," hispermrtislssLTed,Ishallnotemploy any pern <br /> In such manner as to became st;bjoc,to worianan' <br /> Contractor's airing of 8¢ -ce^.rsrt>ng :5 :� G is i=:i t.^. °v iovdi:a: i '.I;i[1_,I:s G6 6rtGr,d^C :; a a40 k tar Whleil ibis p3;mTt is issued,I s{all <br /> employ persons subject to workman's co:rpen5aticli taws of Ca'ifort l ) 1. <br /> I hereby certify that I have prep ,re his appli ati��and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,and rule -and gulati -of the n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X �` <br /> �- <br /> FOR.DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UN ❑ 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„ - „4,,.-DATE _REMITTED--.-.,-...�,.,_..-�-•_. M9UNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS 007w..,? <br /> PENALT 4 <br /> OTHER <br /> OTHER - <br /> 3 -q <br /> Received by Date Receipt No. _Permit No. Iss ance Dae s Mailed Delivered. <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES j 1601 E.HAZELTON AYE..P.O.Box 2009 STOCKTON,CA 95201 <br />