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Applicatiois Will Be Processed When Submitted Properly Completed. BeSureTo sign ineAppitcauon. <br /> 11 . APPLICATION <br /> (For Nan-Transferable Revocable,and Suspendable) $EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> I r <br /> -LIQUID WASTE <br /> Application " hereby ma to car on business in the jurisdictional area of the, an Jo uin Local He tDistrict,. ;. t <br /> r„Business Name (DBA) ?Nl,� x.Address <br /> i Owner, - Address-.7dc <br /> J,Firm Partners, Addresses and Telephone Numbers <br /> dw <br /> a BusinessEmergency Telephone No. <br /> .Telephone No.. - , ... <br /> g <br /> Contractor Licence No. 130M <br /> r Applicants Name (Print} I� Title.. <br /> +� Date ba- <br /> , <br /> Please check Applicable Category (1 7),and F111,in the squired tnformaHon_ <br /> p <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> i :For July 1,- `,June 30, 19{ = =�-- — Disposal-Sites <br /> Description(Make/Yr., Color) _ <br /> Serial No. V CAL. License No. CAL. License Renewal No. <br /> Capacity J� Gal.,'Weights & Measures No. <br /> Equipment Parking Address. �N _ <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30. 19 <br /> .No. of Vehicles Stored i[ <br /> No. of Chemical Toilets Stored .� <br /> - <br /> 3. J__1 PERCOLATION TEST s '" <br /> R.S. or R.C.E. Name <br /> R.S. or R.C.E.No. <br /> TTest Date/Time <br /> Test Location <br /> i 4. 'R SANITATION PERMIT 'II: <br /> Job Address/Location <br /> Owner Address - <br /> ❑ SEPTIC TANK, ❑ CESSPtOOL" ❑ LEACHING FIELD 0 SEEPAGE PIT ❑ PACKAGE PLANT rr <br /> 13 PERMANENT C1 TEMPORARY ❑ NEW EI REPAIR ❑ OTHER J( <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> .Type Construction N� Disposal Site fT <br /> No. of Units �� Equipment Storage/Cleaning Location(s) i <br /> 6. ❑ PACKAGE TREATMENTiPLANT For July 1, -June 30, 19 r <br /> f Operator Name - Where Certified <br /> f Plant Location �! <br /> Plant Capacity <br /> No. Units Served <br /> 7. ❑ LAUNDRY For July 1, '$June 30, 19"�-� - <br /> SIZE: r1l Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. y _ <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 it. ;; "I_ " ,��n r 1 <br /> Homeowttaroflicensedagen.ssignnturocertifiesthcfoSioviEti�: i. l':t;r.,:..,e,.arra.i^ce,; cf.:NC`.kfn v,hicfrthispermlttslssu� s a. no emp <br /> {: in Such manner as to became SUi)1£Ce ti;Y,'01"t(ili:if'S�nrn,11�4iSdiipil Ii1Vi Ot tr . <br /> f <br /> Contractor's firing or suti!�ortracting sign'etur� certifies zim €oHoi ing: "1 certify haat in the performance of the work for which this permit is issued,l shall <br /> employ persons subject to Worknans compensation laws of Calilurnia." <br /> + f hereby certify that- have prepared this'appiicati-- n hat the work-will be done in accordance with San Joaquin County <br /> l ordinances, state la I' , and rules and reguia ' he n Joaquin Local Health District. <br /> , <br /> APPLICANT'S SIGNATURE:X "it" 1 w <br /> 4 <br /> ---FOR.DEPARTMENT USE ONLY.4. <br /> r. ! <br /> + n Fee Is Due: 11ANNUALLYi� ❑ PER UNIT' ❑ PER SITE LJEACH ❑ January.l &Received By January 31` ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> S BASE EXPLANATION AMOUNT DUE CHECKED <br /> .. _ -9. _ - DATE- - -- TE EMITTED - AMOUNT <br /> - ; FEE ,li, / 5 i <br /> LESS <br /> PRORATION <br /> PLUS ;I y <br /> PENALTY: <br /> OTHER Il r [ A­ <br /> OTHER III x <br /> OTHER <br /> Received byDate f Receipt No. ; Per it No - # I ante Dat Mailed Delivered' <br /> 'APPLICANT-RETt1RN ALL COPIES TO: -ENVIRONMENTAL HEALTH-PERMETlSERYICES '"� "'" 1601 E.NAZELTON AVE-,P.O.Box 20119' "STOCKTON,CA 95201 <br />