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��tr Tom:*�? )►'! 4 "►i �', r _ _ <br /> �r Appljcations ill 9e roce 3q When Submitted Properly Completed. Be Sure To Sign The Application. <br /> L U APPLICATION <br /> 'S SEP o sv�[ (For Non-Transferable,Revocable,and Suspendable) <br /> SFp7r1G-. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SM4 lli') L `)C-A . LIQUID WASTE <br /> t_ Applic } h b Cqvy on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA ` Address _ <br /> z Owner - E /' Address ` /C(/f/ fj n/5/ Q9 <br /> Firm Partners, Addresses and Telephone Numbers f <br /> as Business Telephone No. T� J Emergency Telephone No. -- <br /> a Contractor Licence No. <br /> � , �, ` ��/Z ;/Lir( , <br /> Applicants Name (Print) b��� Title Date - <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites i <br /> v <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 i <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. or R.C.E. Name R.S. or R.C.E. No. <br /> Tet Lcation Test Date/Time <br /> 4.X SANITATION PERMIT <br /> Job Addres /Location ' <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACK GE PLANT 1 <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER J <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 -— <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 /> Home owner or licensed agent's signattire certifies the following I certifv th 'inthenorfcmanceoftheworkforwhichthispermitisissued.lshallr 'empioyanyperson � <br /> in such manner as to become sublect to w0;1�man' co n0ans ation laws Lf,,�af'fc a <br /> Contractor's hiring or su4 centracting signature certifies eip olrowins: '`I Certify that in the performance of the work for which this permit;s issued,I shall <br /> employ persons subject t3 r,orkmari s Con'p%n5 fior;la�is of Gaf%lklia.' <br /> I hereby certify that I have prepared this application that the work will be done in accordance with San Joaquin County ' <br /> ordinances, state laws, aid Iee°a regula i oft a Sat Joaquin/Local Health District. <br /> APPLICANT'S SIGNATURE. <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 /> BASE EXPLANATI <br /> BILLING REMITTANCE $ON AMOUNT DUE CHECKED <br /> ' /N DATE, DATE / REMITTED AMOUNT <br /> FEE ✓ t ' iS � � 2l <br /> 01 <br /> LESS (� <br /> PRORATION `�'l <br /> PLUS <br /> PENALTY <br /> OTHER <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.Box 2009 STOCKTON,CA 95201 <br />