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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,'and Suspendable) / SEFTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> Y _ LIQUID WASTE ((( <br /> I Application isere made to c ry b�sines ' the jurisdictional area of the San Joaquin Local H�ealth.District <br /> Business Nam DBA) ddress <br /> a Owner Address. <br /> – <br /> 0 Firm Partners, Addresses and Tele hone Numbers <br /> 0. Business Telephone No. � � Emergency Telephone No. <br /> _J Contractor Licence No. kz k4V <br /> L Applicants Name (Print) fi Tiile ..__ Date f <br /> Please check Applicable Category(14) and Fill in the Required Information _ l <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, rJune 30, 19 Disposal Sites - <br /> Description(Make/Yr., Color) n <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. . <br /> Equipment Parking Address <br /> i 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 s <br /> R.S. or R.C.E. Name R.S.or R.C.E`No. <br /> Test Location Test Date/Time - r '' <br /> 4. JeSANITATION PERMIT <br /> Job Address/Location <br /> Owners��–!����,✓��,e. Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ,SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ALREPAIR ❑ OTHER <br /> i 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19. <br /> -Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> k Plant Location <br /> 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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homeowner or licensed egarlt'ss'sgrraturecertil-the.f0slviinrg:"I rertl in ttlenerformanceet the,vnrk fr,,rV4hich this permit is issued,I shall not employ any psrson <br /> ill such manner as to become subject to i�lrlsm2n':•i..".'1j:=:n5<','.i .r?•r✓s cf Gai::"R . <br /> Contractor's hiring or sub-cartracting sivant ire cc rr+fiF.+= Y tc IoNovviag: i Gcriiiy that IA the performance of the work for which this pal is issued,l shall <br /> employ persons subject to workman s compensation laws of California," "N <br /> I hereby certify that I have prepared this application and tharthe work will be done in accordance with San Joaquin County <br /> ordinances, slate laws, and rul nd reg tions o the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 1 I FOR DEPARTMENT USE ONLY <br /> Fee Is Due: © ANNUALLY ❑ PER UNIT ❑ PER SITE 0 EACH ❑ January 1 &Received By January 31 ❑ July 1 &-Received By July 31 <br /> I BILLING REMITTANCE \ REMIT <br /> BASE EXPLANATION �"'$' 4 AMOUNT DUE CHECKED <br /> DATE DATE. `REMITTED �) AMOUNT <br /> FEEA ;164 <br /> 9 <br /> LESS <br /> PRORATION <br />+ PLUS <br /> PENALTY ✓ <br />} OTHER flu <br /> . <br /> l <br /> OTHER <br /> Received by - - Date Receipt No. Permit No. ssuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL E.,P.O.Box 2009 STOCKTON,CA 95201 <br />