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ApplicationswillBeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION , <br /> .. (For Non-Transferable;'Revocable, and Suspendabl_e)—� <br /> ENVIRONMENTAL HEALTH PERMIT 5EPTAGE <br /> �,: <br /> LIQUID WASTE j6 -fir .I <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,L Business Name (DBA) ` Address ` <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> 5.a Business Telephone No. Emergency Telephone No. <br /> -J Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and FIII 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 r %JJ �N,. - <br /> P y Gal„ Weights & Measures No, <br /> Equipment Parking Address <br /> 2:f❑ PUMPER YARD j <br /> jFJr July 1 �`` i faJune 30, 19 i <br /> No. of Vehicles Stored <br /> .. r <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST � .I` <br /> R.S. or R.C.E. Name ' R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT f rpt J J ,f <br /> Job Address/Location <br /> Owner h, <br /> Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL L-E] -LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT_} <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 t.. r" i <br /> Type Construction _ _ _ Disposal-Site ft <br /> No. of Units a Equipment Storage/Cleaning Locat)on(s) �) <br /> 6. ❑ PACKAGE TREATMENTIPLANT For July 1, -June 30, 19 t I <br /> Operator Name — ! ' t Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served f t <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 T y� <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More-Than 1,000-Sq:-Ft. I y� <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 <br /> HomcownarorliconrAJage-it'ssignaturecortifiestlaefat rfetnq;:`Icerlifyytliaiinthe performanceofthe work for which this permitisissued,ishatinot employ any person <br /> In such manner as to bftomc subject t,workman's co€npensatiort laws ol.Caiifarriii."' 1 <br /> Contractor's hiring or rub-contracting rertif+es Or— ,tollowi -'I celtif-/that io the performance of the work for Miirh this permit is issued,I shall <br /> employ persons aubjecl.o wotlsmali s camtrensalso:l is�s of Califot„ia y I ) " <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, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> E <br /> FOR-DEPAR141 NT USE ONLY I 1 <br /> S <br /> Fee Is Due:,❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH .❑ January 1 &Received;By January 311 ❑ July 1 &Received By July 31 <br /> BASE REMIT <br /> EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CH C ED <br /> -,.,.DATE_-.�_ DATE- REMITTED AMOUNT <br /> FEELESS <br /> i <br /> f � <br /> PRORATION <br /> PLUS t <br /> PENALTY <br /> 1 C - <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.Box 2909 STOCKTON,CA 95201 <br /> 3 ' S <br />