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Applications,Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> i� APPLICATION ` <br /> (For Non-Transferable,'Retrocable and Suspendable) IIIISEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE' <br /> Application.` h reby m e tc)/,arry on business in thejurisdictional area of the San Joaquin Local Health Distract ,S "r, <br /> N Business Name(DBA) =r j Address _ f ' <br /> c+ <br /> " Address <br /> aOwner __. r ti c.r'.0 .•,r,... -. <br /> Firm Partners, Addresses and Ie ra,Nye r F <br /> IL Business Telephone No. i Emergency Telephone No. <br /> P. La•_ v ay 4 <br /> _jContractor Licence No. <br /> Date <br /> L Applicants Name(Print) _ 4 : , : c• : ya g .F - <br /> � r <br /> Please check Applicable Category (14)and Fill in.the Required Information <br /> For❑JuIPUMPER VEHICLE PERM IT,yREGISTRATION (FOREACHSH VEHICLE) 1 <br /> Y ._ - :' <br /> Description(Make/Yr.,-Color) 4 <br /> Serial No. E. CAL. License No. CAL. License Renewal No. <br /> Capacity I, Gal.,Weights &Measures No. ` <br /> Equipment Parking Address t <br /> 2. ❑ PUMPER YARD <br /> For July 1, .. June:30, 19 gip' <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored k f: <br /> 3. ❑ PERCOLATION TEST i <br /> R:S.or R.C.E. No. <br /> R.S.or R.C.E. Name = <br /> R <br /> Test Location R i t Test Dated/Tic e <br /> .4. ❑ SANITATION PERMIT j r ' /f ' �'` <br /> kl,"Job Address/Location <br /> , i Address ' <br /> Owner - <br /> %—SEPTIC TANK ❑ .CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT i p <br /> 11 PERMANENT ❑ )TEMPORARY EW 1 El REPAIR ❑ OTHER r <br /> .5. ❑ CHEMICAL TOILETS Foq�July 1,-Kune 30, 19 <br /> r� <br /> t . �+ ' Disposal Site <br /> Type Construction I -: <br /> No. of Units Equipment Storage/Cleaning Location(s) ; <br /> 6. ❑ .PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> WhereCertified <br /> Operator Name <br />• Plant Location t '� I ' <br /> Plant Capacity No. Units Served ' <br /> 7.-.-13 LAUNDRY For.July 1, -.June 30,,1,9 <br /> ❑ Less Than 1' 00 S . Ft. ❑ More Than 1,000 Sq. Ft. f <br /> SIZE: ,0 q <br /> © Y CLEANING Chemicals Used/Amnunt/Mo. . <br /> Homeowner or licensed agent's signatore:certrfies thefollowina;�;I.Uertif�r that in the performance of the work for whit h-this permit is issued,I shall not emp!oy any person <br /> in such manner as to become sli;3jeet tc work+nan`�compeAsation 121vs of Gu,lforniu." <br /> Contreetoi s hiring or sub-contracting(signature_certifies the foleovvinf;: "I cerllfy that in the performance of the work forwhich this permit is issued,I shall <br /> -employ persons subject to workman'sToinpensatlon lavis.o_f Gaq ornia: �. <br /> _ I hereby certify that l-'have prepared-this application and that the work will 66.done in accordance with San Joaquin County <br /> ordinances, state laws;and rules,an regut ions the San Joaquin Local Health District. <br /> ate <br /> _ � :� >v- _ I �;�, � _���.�.►Gni-� <br /> ,APPLICANT'S SIGNATURE X "'' <br /> FOR DEPARTMENT USE ONLY _ �' - <br /> ( ' <br /> Ja <br />' Fee Is Due: ClANNUALLY ❑ PER UNIT} El PER SITE ❑ EACH ''❑-January i &Received By nuary 31 ❑ July 1 &Received By July 31 <br /> J REMIT <br /> ` BASE EXPLP:NATION""" .rBILLING..:i--4—REMITTANCE-am --»--*�$-y-p- ` AMOUNT DUE CHECKED <br /> .. �_ . . - DATE - DATE REMITTED �. - 'AMOUNT <br /> FEE ' is r <br /> r,- - <br /> LESS P t r <br /> PRORATION ° <br /> #k PLUS -- <br /> (' PENALTY <br /> F_ <br /> n <br /> OTHERp / 1 <br /> Received by = Date Receipt No. Permit No. Issuan a Date - Mailed ---Delivered - <br /> g <br /> f <br /> APPLICANT 'RETURN ALL'COPIES TO: ENVIRONMENTAL"HEALTH PERMIT/SERVICES - 1601 E.HAZ TON AVE.,P.O:Box 2009 STOCKTON,CA 91 <br /> 520 " <br />