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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) SEi,T, <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) 9 Cl4+J 6 1 VV--,y A� J ice. F—. Address CoI�TTy—I'L-- <br /> i Owner VC.`i4-i 6-L 11✓iti! #-.-j Address X02( /J I <br /> a Sy TT�(L <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. 7 4 (P- 4 4,!75 Emergency Telephone No. 2­I--7"`t e-f(423 O�] <br /> a <br /> Contractor Licence No. <br /> W <br /> pplicants Name (Print)� `� I �� �� Title ��� —tt )C X— Date —17-91 <br /> lease 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. QK PERCOLATION TEST — t> <br /> R.S. or R.C.E. Name ep. G, I L,►til- R.S. or R.C.E. No. G '_33 0 33 <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 owner or licensed agent's signature certifies the following:"I certify that Ir.theperformance of ftwork for which this permit is issued,l shall not employ any person <br /> in such manner as to become subject to workman's compensation Iaws of Calitori ia.' <br /> Contractors hiring or sub-contracting signatwo certifies the fotiowing. "I certify that in the performance of the work for which this permit is issued,l shall <br /> employ persons subject to workman's compensation 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 la <br /> XPPLICANT'S <br /> ws, and r and regulatio�e S Joaquin Local Health District.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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT / <br /> FEE 6oOD <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Pkcf ived by Date Receipl No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />