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Applications Will Beessed When Submitted Properly Completed.Be S i o 519n ti nC.+WNrr...+....•.• t1 - <br /> APPU1bA'�QN CV;y <br /> ` . (for Non-Transferable;'Revoaable, and tSuspendable)� Enp '[F <br /> .,*� ENVIRONMENTAL HEAL,THPERM1T <br /> � <br /> LIQUID WASTE <br /> ` Application is hereb ade to carry on business in the jurisdictional area of the San Joaqui.n Local Health District•. ,. <br /> ,r business Name (DBA) Address <br /> i Owner Address!. <br /> 4 .r linY� <br /> J Firm Partners,Addresses and Telephone Numbers .0 <br /> Emergency Telephone No. 'r�9 ��2 <br /> $ Business Telephone No. ' <br /> Contractor Licence No 71 <br /> Title `� Date <br /> L Applicants Name (Print) - <br /> Please check Applicable Category(1-7j and Fill In the Required Information . - ,z _f _ trail`. C 1_j <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June 3% 19 •-- Disposal Sites- <br /> Description(Make/Yr.,Color) - CAL. Licenee Renewal No. <br /> Serial No. CAL.License No. <br /> Capacity Gal„Weights-&Measures No. <br /> Equipment Parking Address - P <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 3d. 19 ' <br /> No.of Vehicles Stored <br /> No.of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST '�7 <br /> R.S.or R.C,E.Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time <br /> t a_t❑ SANITATION PERMIT \ <br /> ob Addresskocation [ <br /> Owner ' Address <br /> ❑ SEPTIC TANK, CESSPOOL ❑ LEACHlNG FIELD - ❑ SEEPAGE PIT 0 PACKAGE PLANT 1 <br /> ❑ PERMANENT ❑ TEMPORARY NEW r ❑ REPAIR L�bTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,--June 34, 19 1� <br /> Type Construction • Disposal Site <br /> No.of UnitsEquipment Storage/Cleaning Location(s) <br /> 5. ❑ PACKAGE TREATMENT PLANT For July 1,-June 3c 19 <br /> ' Where'Certified <br /> Operator Name <br /> Plant Location " . <br /> plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June;34,19 <br /> SIZE: ❑ Less Than 1,000 Sq� Ft., r❑ More Than 1,D00 Sq. Ft.- - - - - - - - <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> k Homnowiieforresnsedagent'ssignaturetowal-astImfoltowiiig:"Irertityy"thatlnThe perfermanceof!be workfor wfii hthispeimitl5issued,lshall notcmployany person <br /> in such manner as to become subject to wdrklha7s corn pan-alien Laws of cali:orltia.' <br /> Contractor's hiring er st if�hrrtrastinp sigRatrrcs cardless the lotirmrno -1 icertity that in the pertormance of the work for which this-permlt Is issued,f shall <br /> 4employ porsorrs subject to workman s compensation{aws Df Califort"a:• <br /> hereby certify that I have preparedthis application and'(hat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules Vd regulations of the San Joaquin Local Health District. _ <br /> APPLICANT'S S1G•,NATU E X r <br /> 1 � .� •- � � t E i <br /> _ _ .-� FOR.otc"PARTMENT USE <br /> -ONLY. <br /> t <br /> E Fee IS DUs:11 ANNUALLY PER UNIT' ❑ PER SITE ❑ EACH ❑ January t B Received By January 31 ❑ July 1&RaCeiVed 13Y <br /> REMIT 31 <br /> 'BASE EXPLANATION =BILLING <br /> REMITTANCE S AMOUNT QUE CHECKED <br /> j--DATE-= DATE REMITTED AMOUNT <br /> FEE <br /> PESS <br /> RORATION <br /> h <br /> PLUS - <br /> ' PENALTY <br /> OTHER <br /> OTHER <br /> Received by - Dare .Receipt No: Permit No. - Iasu a ate Mailed Delivered ; <br /> .. - APPLICANt—RETURN ALL COPIES TO,.' ENVIRONMENTAL HEALTH PERMITlSERVICE9 l6ot E.HA AVE.,P.O.Bax 2009 SYDCKTON,CA 95261 <br /> I _. <br />