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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) SEPPAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl icat� is hereby mad to car fon bus Hess i t juri fictional area of th Jo uin Local Health Dista t <br /> yBusine ame (DBA Address <br /> 4 Own ,Address Y <br /> Firm Partners, Addresses and Tele ho Numbers T <br /> a. Business Telephone No, - _�l G��•.. Emergency Telephone No. <br /> Contractor Licence No. _. .-x -Z <br /> L Applicants Name (.Print) 3 - Title Date —7 4 <br /> Please check Applicable Cate (1-7) and Fill in the Required Information <br /> ,. , s ., . <br /> 1. Q PUMPEft:VEMICLE-PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July.1,1- :y_ June 30-19 - Disposal Sites_ - <br /> Description(Make/Yr.,lGolor) <br /> CAL. License No. GAL. License Renewal No. � <br /> Capacity Gal.,Weights &Measures No. ; <br /> Equipment Parking Address _ t <br /> 2. 11PUMPER YARD <br /> a I <br /> For July 1, June 30, 19 t <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST f <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test�Loion } ' Test Date/Time <br /> 4. L'J SANITATION PERMI I, x=� <br /> Job Address Ocatio 7 r <br /> OwnerAddress <br /> r❑'SE C TANK l 11 CESSPbOL E.'`E] LEACI ZING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT j [] TEMPORARY ` NEW 031REPAIR '$ <br /> 5. ❑ CH EMICAC.TOILETS For July 1, -June 30;4191 <br /> Type Construction} �' --- 4 Disposal Site <br /> No. of Units } I Equipment Storage/Cleaning Location(s) J <br /> 46. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name ( - - Where Certified , <br /> Plant cation <br /> Plant Capacity ( s No. Units Served <br /> 7. ❑ LAUNDRY 'For July 1, June 30, 19 3 f <br />,. SIZE: ❑ Less Than.1,000 Sq'Ft., ❑ More Than 1,000 SZij Et. <br /> ,,s <br /> ❑ Df Y CLEANING Che5iicals,Used/Amount(Mo. t' 7issued, <br /> meowneror cense agemisignaturerariwesd:efollowiro:•`certiffyytrAlmteperformanceof-thewm*forwhich.thispermitisissued'Jin such manner ass to become subject ttl'r arkran':compensa•.i'n iTx, ,,f OI ifornia.Contractor'shiring or sub-contrinting n!"nsturn ;;;es rile 4ollouving: �i certify that in tb*performance of thtwork for which-this pemploy persons subject to workinatis compensalion taws uiOv <br /> I hereby certifythat I have prepared-this application and that the work will be done in accordance with San J <br /> _ordinances,,state laws, and rLry and rea 'ons of he San Joaquin Local Health District- ;g ' <br /> 3 _ <br /> APPLICANT'S SIGNATURE X <br /> — I 4 <br /> FOR DEPARTMENT USE ONLY j <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 ,/$ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> . DATE DATE REMITTED <br /> s.-•fi'- '� - e AMOUNT <br /> FEES` - L <br /> LESS f lj <br /> PRORATION } q <br /> PLUS I <br /> PENALTY - <br /> OTHER_ <br /> OTHER <br /> Received by Date Receipt No. Permit No. 'Issuance Date Mailed I Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH'PERMIT/SERVICES _ 1601 E.HAZELTON AVE„P.O.Box 2009 STOCKTON,CA 95,201 <br />