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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> t (For Non-Transferable, Revocable,and Suspendable) SEPTAOF <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i ereby made t arrU on buSlxwqs in th juris ' nal area of the Sa oaqu ocal Health District <br /> OF Business NkRiV DBA) Address � <br /> aOwner n Address - =— — <br /> J Firm Partners, Addresses and�Te� phone Num ers <br /> aBusiness Telephone No. (szQ r Emergency Telephone No. <br /> Contractor Licence No. — ff <br /> L Applicants Name (Print*Ctegory <br /> o S rTitle Date <br /> Please check Applicabl (1-7)and Fill in the Required Infornlation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <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. orff C.E. Name R.S.or R.C.E. No. <br /> Test L�6cation Test Date/Time <br /> 4. (�� SANITATION PERMIT <br /> Job Addres / ocation <br /> Owner a Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELDS GE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 11 TEMPORARY 1:1 NEW EPAIR ❑ OTHER _ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 _ f1 <br /> Type Construction Disposal Site + <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name _— Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> tiomeowner orlicensed agent's signaturecertMenthofollowing:"Iceriif)tthplift4performanceoftheworkforwhichthispermitisissued,Ishallnotemployanyperson <br /> in such manner as to become subject to workman's compensation laws of c4to! l- <br /> Contraetor•s hiring or sub-contacting signature certifies the following: 'i certify that in the performance of the work for which this permit is issued.I shall <br /> employ personssubject to workman's compensation laws of California." <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an rules d regulations of the Sa "LocalHealth Distri t. <br /> APPLICANT'S SIGNATURE X 00 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION REMITTED AMOUNT DUE CHECKED <br /> DATE DATE AMOUNT <br /> a C1 , <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> { <br /> OTHER <br /> I <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STO jC1KTON,CA 95201 <br />