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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) SEPTAr� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE Z —37 <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Loc trict <br /> H Business Name (DBA) 14N !NL Address Zg2,5 /"IF <br /> a Owner �' Address (06o M t C4 Wrr'O✓g RD. <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 43`o-135 9X3- 24189 Emergency Telephone No. <br /> Contractor Licence No. /1 <br /> a Applicants Name (Print) ('�/t�VDlc� d. � /r}J�c Title Date Nw <br /> Please 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. 0 PERCOLATION TEST <br /> R.S. or R.C.E. Name NALb R.S. or R.C.E. No. 3$g <br /> Test Location /rTest Date/Time 27 <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner _ Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified _ <br /> Plant Location <br /> Plant Capacity _ No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE ❑ Less Than 1.000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. _. <br /> ❑ DRY CLEANING. Chemicals Used/Amount/Mo. <br /> Herne ew.,er^•fieertssd e9ertt'tt siyrrehrrr rerti�ieathe fpnowirg!"I C�rtffy that in the pertorrr!at►t 1!of the wp rl <br /> in such mance ds to become$ub00 to w0rkelan'S rompenvatia-1 taws n}ralifcrnia" <forwhkh this peimitis issued.f Shall not emplmrany person <br /> COrtirector's hiring a SUtr COrltti�ctlMl wrra7h01) -whirl:t're �WfOA irlQ: I cef'.:`y tha:in the p OI%niti;C2 Ci tli%vfork fpr which tys pefmit iS IS;JOC.I Shall <br /> einploY persons subject to wurkataii s coifi 1,;rsaitot,law;,«f C«ti,3;qlu.__ <br /> a <br /> I hereby certify that I have prepared this applicaRion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regula ' s'ofSa n f oaquilh Local Health District. %a' 2-1 qp� <br /> APPLICANT'S SIGNATURE X <br /> { <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ianqary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BG DATE E REMITTED AMOUNT DUE CHECKED <br /> DATE <br /> AMOUNT <br /> FEE /D /�' /•�• / OV' �d OGr BD <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER �:~✓ - "- <br /> OTHER <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />