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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. ' <br /> APPLICATION y' <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEP7AGE <br /> LIQUID WASTE <br /> Application i hereby made tp carry on business in the"uris tional area of the San Joaquin Local Health District <br /> N � <br /> Business Nam BA) Address 4r� `i' 76 7 ��` <br /> z Owner Address <br /> Firm Partners, Addresses and Telephone Numbers t� <br /> a. Business Telephone No. Emergency Telephone No. i <br /> Contractor Licence No. Z ZZ <br /> LApplicants Name_(Print) -�- Title Date S� I <br /> Please theck'Applicable,Category (1-7) and Fill in the Required In ormation <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 /> r . <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 .E. Name R.S. or R.C.E. No. <br /> Test cation Test Date/Time <br /> 4. SANITATION PERMIT I <br /> Job Address/Le ation l , <br /> Owner Address <br /> ❑ 'SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ ❑ PACKAGE PLANT <br /> 1:1PERMANENT ❑ TEMPORARY 1:1 NEW REPAIR ❑ OTHERS <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.,F__t. <br /> ❑ DRYRCLEANING, Chemicals Used/Amount/Mo. <br /> otneownerorlfeensedagertYssEgna>•„reeertttlearehefotl wing."I certify that intheperfor anceottheworkforwhichthispennitisissued,Ishagnotemployanyperson <br /> in such manner as to become sub(ect to workman 5 ComMnsatlon laws of Ca ifornla.' <br /> CeMrsc eros subjifty or auorkman's c r►g lfgmltrl la s t$f f,s the toilaMArly: "I defy that in the performance of the work for which this Wmit is issuetl,t shall <br /> t fnpfoy persons subject to workman's compensation laws 4!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 s and regulations of an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X -9 <br /> r <br /> 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 /> BILLING REMITTANCE 1 $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE' DATE y REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS 2 <br /> i. PENALTY vvv <br /> OTHER <br /> OTHER <br /> e <br /> Received by Date _ Receipt No. Permit No. IstwancPIDate Mailed Deli red <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201;__� <br />