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f r t;` Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. _ <br /> -� <br /> APPLICATION <br /> i W (For Non-Transferable, Revocable,and Suspendable) <br /> " ENVIRONMENTAL HEALTH PERMIT f SEPTAGE <br /> LiQUIo WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District Ct . <br /> f h Business a e (DBA) r y� ,, Address (V <br /> r z Owner-107,2,14r �- ( Address_ <br /> K C <br /> f1 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. - Jek_23Emergency Telephone No. <br /> Contractor Licence No. 0WAS- <br /> LApphcants Name (Print) 1� A-V 4 ] fL V&1A A Title Date ^-�6 <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 /> f. Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> I 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 Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job.Address/Lo ation � {� <br /> Owner �trri.an L' Si Ivet F Address <br /> W—SEPTIC TANK ❑.CESSPOOL 9;-- ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> i ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER V <br /> 5. ❑ CH TICAL TOIL TS For J y 1, -June <br /> 430, 19 <br /> Type Construction X QV- Disposal Site Q <br /> IF <br /> No. of Units- Equipment Storage/Cleaning Location(s) <br /> t <br /> _ <br /> - 6. ❑ PACKAGE_-TREATMENT PLANT For July 1, -June`.30, 19 s <br /> " f <br /> Operator NamWhere Certified <br /> e f <br /> Plant Location <br /> 'No. Units Served <br /> Plant Capacity , <br /> 7.- ❑ LAUNDRY For July 1, -Jun-e'-30, 19 <br /> SIZE: -❑ Less Than 1,000 Sq. Ft—., ❑ More Than 1,000 Sq:-Ft. <br /> R <br /> 11-DRY CLEANING, Chemicals Used/Amount/.Mo. <br /> ifomeaFwne►orficensedagent's signature certiftathefotlowing:"Icertifyth at in the performance of the work for which thsspermit isissued,Ishall notempfoyonypiff t <br /> Y in such manner as to become subject to 1•,orkmzr's compensaiian laws of California." � <br /> Centractor's hiring or sub-contracting si;vat�,ra'certifies the following: "I certify that in the performance of the work for which this permit is issued,I shaft <br /> Employ persons subject to workman's compensation laws of California." <br /> f <br /> sf <br /> 1 hereby certify that;l have prepared-this application and that the work will be done in accordance with San Joaquin Comrity'': <br /> ordinances, state laws, and rules and regulatioris of a San JcAuta Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> , r <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Dile:-ElANNUALLY ❑ PER UNIT El PER SITE ❑*EACH ❑ January 1 &Received By January 31 © July 1 &Received By July 31•_, <br /> F REMIT <br /> t $ AMOUNT DUE CHECKED # <br /> BILLING REMITTANCE <br /> BASE EXPLANATION DATE ,�, DATE REMITTED AMOUNT <br /> f FEE <br /> LESS IL <br /> PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER �. jfl�✓ <br /> OTHER <br /> Recei d by Dat Receipt No. Permit No. Issuance Date Mailed Delivered <br /> _ A; '•ICrANY=-t7ETURN ALL COPIES TO: ENVIRONMENTAL F4EALTH PERMITISERVICES 1801 E.HAZELTON AYE.,P.O.Boz 2009 STOCKTON,GAr..5201 - <br />