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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Si."Tjtie Appli,` 2q?rt. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable)ENV1R0MENTW{ LTH <br /> ENVIRONMENTAL HEALTH PERMIT FERW_ MICM <br /> LIQUID WASTE / 'r e_ <br /> Application s hereby made�to�carry business in the jurisdictional area of the'San <br /> �J7oaquin Local Health District <br /> w Business Name (DBA) 11N1 VA C7 4 P At z 7 Addresss �- W �— I—�� LUbt f i i�0 <br /> z Owner CQfy_� /Iy/frJyPP Address h3c�'O —IV L lC4-4f7- <br /> 4 . - <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Emergency Telephone No. <br /> 4 <br /> Contractor Licence No. <br /> L Applicants Name (Print) Z Title �� 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. of Chemical Toilets Stored PT <br /> 3. K PERCOLATION TEST <br /> R.C.E. Name <br /> � U 11 n O (l 1 r►SIror R.C.E. No. <br /> Test Location 4 TL,,S A✓ Zzzcw Hyl' Test Date/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 /> Homeowner or licensed ��"t�t1�that intMpet*manceol!he work for wMebthis permit isissued.Ishall not employ any person <br /> in such manner as to become subject to wolktna' ;ompe1r7at*t l aft of Cal ierria. <br /> Contracw+'s hiri or sub-contracture signature certWwp t!,#* MNevAnly I Cyr;" :2' �tl urmafri epi;the Murk fOr which this permit t9 issued.I shat{ <br /> employ parsons subject to workman's compensation laws of":f:o,n►a. <br /> I hereby certify that I have prepay tFtis applicationthat work will be done in accordance with San Joaquin County <br /> ordinances, state lavy d regulations o e 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 /> DATE DATE REMITTED AMOUNT <br /> ZF <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ,OTHER <br /> OTHER <br /> eived by 1 Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> E.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AV <br />