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_Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> i (For Non-Transferable;-Revocable,'and Suspendable) S PTAGE <br /> it 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 Dist act r <br /> OF Business Name (DBA) d Address <br /> z Owner Address <br /> a <br /> : Firm Partners, Addresses and Telephone Nu ber <br /> aBusiness Telephone No. �p a l Emergency Telephone No.; x <br /> Contractor Licence No. <br /> LApplicants Name {Print) ,� Title C�'T�I�il�O� Date ar <br /> Please check Applicable Category (1-7)and fill in the quired Information rE ..y r, ,-.. •..i, 0-,.- ,w <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Fo`r July 1, June 30, 19r -=Disposal-Sites — - <br /> Description(Make/Yr., Color) <br /> Serial No. CAS_. License No. CAL. License Renewal No. <br /> Capacity i� `Gal:, Weights& Measures No. ) <br /> Equipment Parking Address i <br /> F 2. ❑ PUMPER YARD 3i <br /> For July 1, June 30, 19:F <br /> No. of Vehicles Stored _ V <br /> No. of Chemical Toilets Stored ~ <br /> 3. ❑ PERCOLATION TEST 1 { F <br /> R.S. or R.C.E. Name _ R:S.or R.C.E.No. <br /> Test Location '� Test DatelTime <br /> 4. JV SANITATION PERMIT <br /> Job Address/Location_5_94 E Q0 i -- <br /> Te a �'1 ne �r Address�4� S M 7 M <br /> Owner o - <br /> 19 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 /> Na. of Units 3 Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 6 <br /> Operator Name - - Where Certified <br /> Plant Location <br /> Plant Capacity No; Units Served t a <br /> 7! d LAUNDRY For July 1, -'!June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. F=t., ❑ More Than 1,000 Sq.fl. <br /> DRY CLEANING, Chemicals 1 sed/Amount/Mo. k <br /> Nome ownarortirsnsedege that istthe performance ofthe work for wJild-thispermit isissued,[shall not employ anyperson <br /> in-such manner as to become subject to worPrian's compensatiod law:of California: ! i <br /> Contractor's hlri�g pr sub-contracting s:gnat� rcrt:t+s '�,; -cli, yid. 'i certify that in the per.iarmance of the work forwhicft this permit is issueQ.F shafE <br /> employ•pefsons subject to woikr:asi s eomnensa,tior.ia.vv of Catffo is <br /> i <br /> I hereby certify that'i have prepared this application and that 1 work will be-done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulatio 0 San` uin Local Health District. + _ <br /> ! i. <br /> APPLICA•NT'S SIGNATURE X <br /> a: <br /> -FOR DEPARTMENT USE ONLY -` <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT' El PER SITE 11 EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> ,� - -^ 4— -- REMIT: rw <br /> BILLING REMITTANCE $ i ^` <br /> BASE EXPLANATION AMOUNT DUE CHECKED (� <br /> t DATE DATE REMITTEDAMOUNT <br /> T <br /> FEE <br /> LESS '. <br /> PROBATION,, <br /> PLUS } <br /> PENALTY <br /> OTHER `. .. f <br /> I � <br /> OTHER. � - - ----- <br /> .:t...r.Q-p-....�: t.... y ..:,.,�.��..... � a ! _ ..,..--...�w..::�•--..-.-.'.-F-`—.._'•--•---- - <br /> Received by Date I Receipt No. Permit No. —issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH 7PERMIT%SERVICES 1601 E.HAZELTON AVE.;P.O.Box 2009 —STOCKTON,CA 95201 <br />