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Applications Will Be Processed When Submitted ProperlyCompletea. <br /> APPLICATION <br /> *� (For Non-Transferable, Revocable,and Suspendabie) SEPTAG> y <br /> ENVIRONMENTAL HEALTH PERMIT <br /> y LIQUID WASTE <br /> Application is her by made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Address <br /> Business Name (DBA) OF Address <br /> z Owner <br /> d <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> Q. Business Telephone No. <br /> Contractor Licence No. Ti11e. Date <br /> L Applicants Name (Print) ) j <br /> Please check Applicable Category(1-7)"and Fill in the Required Information r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) � <br /> For-July'1, <br /> June 30 19 - Disposal Sites <br /> � , �.° <br /> Description(Make/Yr.,,CColor) CAL. License Renewal No. <br /> Serial No: 1.100 <br /> CAL. License"No. ' <br /> ef­ <br /> Capacity Gal.,Weights &Measures No. .� <br /> r <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 R.S. or R.C.E. No. f fa <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location 1.1 <br /> q. X SANITATION PERMIT <br /> Job Addr /Location <br /> Ad r ss <br /> OwnerEl PACKAGE PLANT <br /> SEPTIC TANK 11 CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ OTHER <br /> ❑ TEMPORARY NEW - EI � }} <br /> PERMANENT _ V <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 rALt L� <br /> of Units <br /> Disposal Site <br /> Type Construction r+ t 0.1 1 1 <br /> G a inII~ <br /> No. <br /> Equipment to leang:Locaticn(s) w } <br /> t g. ❑ PACKAGE TREATMENT PLANT For July 1, -Jurie 30, 19 Certified1. <br /> Where� ,r � <br /> Operator Name <br /> Plant Location No. Units Served ' <br /> plant Capacity s <br /> 7. 11 LAUNDRY For July 1, -June 30, 19 ; <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 121 DRY CLEANING, Chemicals Used/Amount/Mo. >!* y <br /> yomeowrtgrortirensedanent'gsig!tr'srP^^rtifis-thefollo+vina:"Icertity?hat tntheperfarmancsoft.heKOrkf rivhichth'Ispermitisissued.IshaAnot employ any person <br /> In Such maril d5 to Oacome Stlbinnl t?woo ktrar}t C,�mpens;?i3o t l5ws�f cafifDffika.' . i <br /> Contractor's ;icing or sub-contracting s` nature.certif os t*r 'a0110vvi"9: "I certify that is the performance of the WoI which this permit i5 issued,/sllali <br /> employ persons�t.5ject to WOFI(Mar's:;=Pens til lay.::t;i <br /> � <br /> Yhe <br /> I hereby certify that I have prepared this application and that _ Local Hwork will be done <br /> done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and regulati ns of the San Joaquin <br /> APPLICANT'S SIGNAtURE X <br /> Jr <br /> _ d i <br /> FOR DEPARTMENT USE-ONLY14 <br /> �.`.� _ ► 1 <br /> �� ❑ January 1_R Received By Sanuary 31 � ❑``July?_&Received By.July <br /> Fee Is Due: ❑ ANI DALLY ❑ PER UNIT ❑ PER SITE ❑ EACH REMIT <br /> + - BILLING REMITTANCE $ AMOUNT DUE CHECKED: <br /> Allow BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE .- `` ` W-1" t .► ! <br /> LESS <br /> PRORATION <br /> I PLUS <br /> PENALTY' <br /> OTHER—'. <br /> e - <br /> i.OTHER: <br /> "' ti _ �� � Issuance Date Mailed Delivered <br /> } ate Rec ipt No. STOCKTON,CA,95201 <br /> Permit No- ' <br /> Received by �. - 1601 E.HAZELTON AVE.,P.O.BOX 2009 ' <br /> "APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />