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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> r (For Non-Transferable Revocable,and Suspendable) SEPTAOt <br /> ENVIRONMENT4L HEALTH RERMIT <br /> if!1 LIQUID WASTE <br /> d to ca ry o si e s i uris is onal area of the n J aquin LQ al Health District <br /> Applicat'on is h eby <br /> yBusiness Name{DBA) dress" 0 �C L.-(s - <br /> z Owner-.L- L• Address <br /> J Firm Partners, Addresses an Tele ho mb rs _ <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. :,. <br /> a App"licants-Name (Print] Title. D to ' <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> J.1-11 PUMPER-VEHICL-E"PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Foe July 1,' r " June 30, 19 a "- - - "Disposal"Sites " " - <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. ' I-.- -! 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. 0 PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S.or R.C.E. No. <br /> r Test:Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT �-- <br /> Job Address/L'ocat�on <br /> Owner <br /> Addres , <br /> ElSEPTIC TANK. C1CESSPOOL LEACHING FIELD EEPAGE PIT 0 PACKAGE PLANT Q <br /> 11 PERMANENT El TEMPORARY EW 9�IEPAIR ❑ OTHER <br /> 5. CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> w No. of Units Equipment Storage/Cleaning Location(s) <br /> S. PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> k Operator Name •d Where Certified" <br /> Plant Location t <br /> i 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. TLI <br /> r Z' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t. <br /> i Horneownwortieensedagert'saignaturecartifiesthefollovonp:"I certify thatinthe performance ofihework�forwhiththis permit isissued,Isha3not employ any pdrsen= <br /> in such manner as to becofne;subjei t to WOrkfnan's GOTIPMMaticn.taws Of 01ifornia ' r . i <br /> Cont6ctor'� hiring or' sub-contracting d9natum Ortifies t`ee-toflovwog: 'I certify tha in the parformattce of the work for.which this permit is issued,I shall <br /> employ petsonssubject to workman's.compensatlon lav '1-Cau:rnia.:., ^`"- " <br /> j I hereby' certify th�­ ave 'ep ed i, a -p c -65- and that the work will be done in accordance with San Joaquin County <br /> ordinances, state and r gul 'o f the San quirt Local Health District. <br /> APPLICANT'S SIGNATURE.. <br /> t - FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11ANNUALLY C] PER UNIT ❑ PER SITE 11EACH 10 January 1 8 Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> BILLING REfiAITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> r DATE .!DATE REMITTED. AMOUNT <br /> i FEE <br />[ LESS <br /> it PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER I. <br /> L <br /> Received by Date Receipt No, Permit No. _ Issuance.Date .Mailed Delivered q <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.-,P.O.Box 2009 STOCKTON,CA 95201 <br />