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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION07- <br /> � � <br /> (For Non-Transferable,Revocable,and Suspendable) SEP <br /> ;��' O VE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is her by�ma�dde�to carry on business in the jurisdictional area of t�San Jgagwuin Local Health District . t <br /> y Business Name (DBA) PAP-1Z k4V:�� Address 1r' RM 14SV- e S`" <br /> i Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 4 G G 5k. Emergency Telephone No. <br /> -J Contractor Licence No. zs Ap <br /> Applicants Name (Print) M 1 S Title AI� � 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 <br /> Description(Make/Yr., Color) r <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. or R.C.E. Name R.S.or R.C.E. No_ <br /> Test ocation Test Date/Time <br /> 4. KSANITATION PERMIT = I <br /> Job Address/ ocatio <br /> Owner , Address <br /> 11SEPTIC TANK ❑ CESSPOOL .LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> 9PERMANENT ❑ TEMPORARY 13NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equiprpent Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For Jdriy 1,-June✓30, 19 <br /> Operator Name f Where Certified <br /> Plant Location <br /> Plant Capacity s No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -Ane 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sqt af=t., ❑ M Than 1,000 Sq. Ft. <br /> ❑ D§XW4ANeINC�Che�tr icals,U d/Amoun Mo. <br /> or agents mnatumcertffinattm folfowfiffgf:('I certify!hatln the po0ormance of the work forwhich this permit is issued,I shall not employ any per—n <br /> In such manner as to become subject to Workman'$compensation laws of Califofns:• <br /> Oontrectors twRnq or subw conitracting,sigrq,arrs.certifies tf�c Cotbwtag: i cprtsty aha=in the petlormance of the work for which this permit is issued,l shall <br /> employ persons subject to workmarfs compensation taws of Catifornia.' <br /> I hereby certify that I h pr <br /> epared;tttis application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, ,nd ules andjegul ns of an Jp7n al Health District. <br /> APPLICANT'S SIGNATURE X <br /> DEPARTMENT USE ONLYs <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ AER$ITE ❑ EAC ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 : <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> g L� mD <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Is uanc 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 />