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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) c-1.,'T—'GE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> r r <br /> Application is hereby ade to carryon s' ess the jurisdictional area of th n Joaquii5Local He Distri�t <br /> �, Busine,C�sa.pv���+N.�ame (DBA0. 1. Address�+� b!!�u- �s� -r <br /> a OwneC_a ftea Address <br /> Firm Partners, Addresses and•TTelephonemgrs <br /> �i Business Telephone N( q <br /> Emergency Telephone No. <br /> Contractor Licence No. LZLe <br /> Applicants Name (Print) Title Date <br /> �. Please check Applicable Cat ory(1-7) and Fill in a Required Information /� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) V <br /> For July 1, June 30, 19 Disposal Sites <br /> r 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.For July 1, June 30, 19 <br /> No. of Vehicles Stored - <br /> r, No. of Chemical Toilets Stored - <br /> 3. ❑ PERCOLATION TEST --A.S.or R.C.E. Name R.S.or R.C.E.No. <br /> Test Lation Test Date/Time <br /> 4. L'J SANITATION PERMIT _ <br /> Job Addr /Lo anon <br /> Owner i� Address <br /> (�, �SEPTIC TANK ❑ CESSPOOL O LEACHING FIELD (`SEEPAGE PIT PACKAGE PLANT <br /> ta'PERMANENT ❑ TEMPORARY WNEW 13REPAIR 11OTHER <br /> S. ❑ 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 oz <br /> a'3 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 /> a LSed/AmounVM <br /> ❑ DRY ,�( �3 Pbb en i�19-aturel�rtr, ilisthefdtovWrg:"L certitythal inthepertocmanceofthewark for which this <br /> N such manner as to become subject to Workman's compensation laws of California � permit is Issued,I shalt not empfoyany P�r <br /> Lririrp a sub-contractingSLsnaturrPersons subject to workmans compcnsatian laws of California.,,u S iiY, <br /> es w <br /> employ fokoyri-g: -t certify that in the parfarmarra of tho work for which this permit is Issued,I shat <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, an les anti r"ulns f the San Joaquin Local Health District. <br /> r <br /> APPLICANTS SIGNATURE X <br /> i <br /> FOR DEPARTMEtlTMSE_QNLY.__.. <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January/8 Received By January 31 ❑ July 1 6 Received By July31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED ' <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �.. Redeived by Data Receipt N. Perm-No. lissuante Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,P.O.Im 2009 STOCKTON.CA 9SM1 w I <br /> .. ._ 9 <br />