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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) SEPT1\GE <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) /U/L.c? ,(71pie1�6�(r ,�/4.e/1/1S _ _ Address fekQ,' fl ./) Ar A A (7� q. _ <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. S2-62 E3 <br /> a <br /> Applicants Name (Print. Ti A-J Title BGIT Date <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. o heroical Toilets Stored <br /> 3. ;4 <br /> -PERCOLATION T p <br /> R.S. or R.C.E. Name /C Eluf6l /COQ ZE R.S. or R.C.E. No. '57 <br /> Test Location __d12A-1�2 C /� % Test nate/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 orlicanasdAgent'$ai9"Atursce"Ifieebsefotio ing:"I codify Mal inth.pealmItnceoftAeworkforwhWhthispermitisissued.tshal)notemployanypersor' <br /> in such manner as to bpmme sweet to workman' Compensation tavrs a♦calife"kat txrtif 111$1 2f*ptrfOfMance of the work tar which this permit is issued,I shall <br /> aetor'a <br /> Cont+ hiring or svc <br /> b —meting $11911`1110176 C'"ifts the tONOWN g ! <br /> employ persons suboct to workman's comPtISatiOft taws Of Cz9wilwa <br /> I hereby certify that I have prepared this applicatio a the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules regulatio th oaquin Local Health District. <br /> APPLICANT'S 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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> v DATE DATE REMITTED ^AMOUNT <br /> FEE 00 e�^ - �� �c7 1 •� C. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Rfteived try 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.Box 2009 STOCKTON,CA 95201 <br />