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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) SEPTA('F <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 /> yBusiness Name (DBA) Address <br /> a Owner s e rte/ G Address /-3 . Ggl�� <br /> Firm Partners, Addresses and Telephone Numbers <br /> R <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) �`r�t///9 C //ms! 1 Title /'����''%%l Date li <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) � o� a7f ��9.fL0 <br /> For July 1, June 30, 19 Disposal Sites 4"E- /¢G¢¢ <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 /> R71lhiiw R.C.E. Name ,�cuAir/ —,/ Brim R.C.E. No. <br /> Test Location mer° /r74 '9,e�r� /�V Test Date/Time P✓Q�Q J���,�r„ ,��• - ��S <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 /> ❑ QRY CLEANING, Chemicals Used/Amount/Mo. <br /> ome owner of licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shalt not employ any person <br /> In such manner as to become subject to workman's compensation laws of Califor:tia.' <br /> Contractor's hi• or sub-contracting signature eert:ties the following: "I certify that in the performance of the work for which this permit is issued,I shall <br /> employ persmis yub ect 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 laws, and les and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUREX "J <br /> C_l <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 /> QAMOUNT <br /> FEE r pm <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.Box 2009 STOCKTON,CA 95201 <br />