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—Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION _., ; , 7 r <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> 5EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT t <br /> LIQUID WASTE ; <br /> Application i heLriLby made to carry on busin s in the jurisdictional area of a San oaquin Local Health istrict <br /> U)_ <br /> Business Name (DBA) 1 Address 2 <br /> aOwner -.. .__._ Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No; Emergency Telephone No.- <br /> {.r <br /> Contractor Licence No. r <br /> L Applicants Name (Print, ESE R LiS 1&4::S: Title A Date <br /> Please check Applicable Category (14) and fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,.. _ _June 30;Y9 =-: Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. ' CAL License Renewal.No. <br /> Capacity Gal.,Weights & Measures No. r <br /> L 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. Cl PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No.. <br /> Test ation Test Date/Time <br /> 4. LW-SANITATION PERMIT-' r r <br /> Job Addr /Location C <br /> Owner_ 11=5 IL-•1- ate. Addre s <br /> ❑ SEPTIC TANK ❑'CESSPOOLEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ` ❑ NEW )24EPAIR El'OTHER Q <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Gleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name a Where Certified _- <br /> Plant Location t <br /> Plant Capacity ` No. Units Served # �! <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 1 } { <br /> 'SIZE: ❑ Less Than 11,000 Sq. Ft., ❑ More Than 1,000 Sq.-Ft. <br /> DRY CLEANING, Chemicals Used/Amolint/Mo. <br /> H�mAawllorerlirensedaneRt'ss;gaa:tlrec,r:lt.estheFaHoµsi� "Icrrt.ify'thatil?the{12r€orMarco eft'1cwwkfor v.,1N hthisllnrmitisissued,Ishallpoternpioyanypersotl <br /> ,. in 5_1ch manner ES to becp,T.E'sui'_jeCt IG L'lDrXi?tinil y is n?�P.nSeai(3ri Ic',.Sdr Ot%ii i{1f.ii:1 Contractor's hiring or.Su`J•ar3:l;rAc'i1y' �3r ^; ti1n:i t iliC 'ri i B C'r f to Y;C{k for':lhiCri this permit IS issued,I Shall <br /> cir, ,a, certifies :lie o;Owing.; Ni- <br /> employ persons subject to workman's co perlsaiion!avis �rnia. <br /> p t ` <br /> I hereby certify that I helpared this application and that t work will on in accordance with San Joaquin Countyordinances, state laws, d regulation the San In Lo ea Di trict. <br /> .APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> - Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 0 January 7&Received4f)anuary 31 ❑ July 1 &_Received By July'31 <br /> . REMIT i <br /> $ k <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE- DATE- REMITTED AMOUNT - <br /> FEE .�� <br /> LESS <br /> PRORATION ,� ?-• - -_ - <br /> PLUS <br /> ` } PENALTY <br /> ^ OTHER <br /> OTHER <br /> Y <br /> t <br /> Received by Date _ Recei.pt No. Permit No. Issuance/Date- Mailed Delivered. <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 20D9 STOCKTON,CA 95201 - <br />