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Applications Will Be Processed When Submitted Properly Completed. Be SureTo Sign TheApplication. <br /> APPLICATION <br /> (0111111ONon-Transferable, Revocable, and Suspendable)'�w SEWGE <br /> ENVIRONMENTAL HEALTH PERMITlC J �� <br /> LIQUID WASTE <br /> Applica io is ere me o car n busines in the jurisdictional area of the San Joaquin Local Health Dis rlc <br /> m Business Name (DBA) Address_12 ,F 7-2 6 <br /> iOwner Address <br /> Firm Partners, Addresses and Telephone Numbers A ZD9 /•S8 b <br /> iBusiness Telephone No. S 1A Emergency Telephone No. S <br /> A.Contractor Licence No. rlJ <br /> � <br /> Applicants Name (Print)51 A. Title Date �q <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 /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. 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. ❑ 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/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 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 /> 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 /> Home ovn rorlicensed agent's signaturecentifiesthe following"Itertify that in the performance of the work for which this permit is issued,l shall no:employ any pemrr <br /> in such manner as to become suoiect Po workman compensation laws of California <br /> Contractor's hiring or sub-caxracting signature certifies the foNowing: 'I certify that in the performance of the work for which this permit is issued,I shalt <br /> employ persons subject to workman's compensduon laws of California." <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE E <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> /DATE Q DAT�E.J /R�EMITtTE�D AMOUNT <br /> FEE Z r_I S/ D6 i LYs <br /> LESS L� <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> LJil,tAa�-( a/tg(s8 1� 37a 8/,yea L. <br /> Received by Date Receipt No. Permit No. Issuance Oete ...1. Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16011 E.HAZELTON AVE.,P.O.Boa 21109 STOCKTON,CA NMI <br />