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ApplicationsWill Be Processed When Submitted Properly Completed. Bee Sure T Sign The Application.
<br /> APPLICATION
<br /> (For Non-Transferable,Revocable,'and Suspendable)
<br /> ENVIRONMENTAL HEALTH PERMIT SEi'TAGE
<br /> LIQUID WASTE
<br /> Application is hereby made to carry on business in the l jurisdictionaarea of the San Joaquin Local Health District
<br /> Business Name (DBA)
<br /> ,�, � r P. t _ ~
<br /> I.-
<br /> Owner Address p'Dk L?le 1 � kN
<br /> Address. I.
<br /> nu Firm Partners, Addresses and Telephone Numbers ~
<br /> aBusiness Telephone No. b 19-- d
<br /> Contractor Licence No. 2 Emergency Telephone No.
<br /> L Applicants Name (Print) Titles
<br /> Please check Applicable Category(1,-7) and Fill in the Required
<br /> Date
<br /> ion
<br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE)
<br /> a _
<br /> For July 1; June.30, 19— Disposal Sites 1
<br /> Description(Make/Yr., Color)
<br /> Serial No. CAL. License No. -
<br /> Capacity KCAL. License Renewal No.
<br /> Gal.,,Weights & Mel asur'es No. x
<br /> Equipment Parkirfg Address
<br /> 2. ❑ PUMPER YARD R ,
<br /> For July 1, I June 30, 19
<br /> No. of Vehicles Stored ,
<br /> No. of Chemical Toilets Stored III
<br /> 3. 13 PERCOLATION TEST
<br /> r
<br /> j 4
<br /> R.S. or R.C.E. Name .,,t
<br /> ' •
<br /> e R.S. or R.C.E. No. `f
<br /> Test Location Y
<br /> Test Date/Time r
<br /> 4. )S SANITATION PERMIT u w
<br /> Job Address/Location op 7 r 0"Gly
<br /> PSERMANENTS
<br /> Owner u � AddressEPTIC"TANK ,❑ CESSPOOL BLEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT❑ TEMPORARY_ MrNEW ❑ REPAIR ❑ OTHER -
<br /> 5. ❑ CHEMICAL TOILETS Fior July 1, -June 30, 19 l�
<br /> Type Construction Disposal Site
<br /> No. of Units, I Equipment Storage/Cleaning Location(s)
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t
<br /> „ Operator Name _ - � ------•------ r1
<br /> Plant Location 1 - Where Certified' t
<br /> I
<br /> Plant Capacity t
<br /> No. Units Served
<br /> ;7. C] LAUNDRY For July 1, -June 30, 19 _ „�� 1 _
<br /> SIZE; 11 Less:,
<br /> 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.
<br /> C1DRY CLEANING, Chemicals Used/Amount/Mo. k '
<br /> _
<br /> Rome owner orlicensed agenr'ssignsi?..rea;r�rtiiiest'�a'a! rn�, tcv �i� ;-r;l,.-.; ,, � r � .
<br /> in such manner as to become subjecr Ic vnrk n It s i;nm;, >v.:r„a,,` r, r'r `'t^.h tjsi *ci nft is is�rietl,I sisal{not employ any person
<br /> Contractor's hiring or sub-ccntractitta uizjnat.s�c4, 'Ifi�J:, the fotlotv,nr: I C�•r;iiy?h:+.irr A nP n4 a f
<br /> empl0Ypersons subject to workman's coripensaffu E�a;:'�ci California." t's'' 3p1 me•.' he work for 4v£ich this permit is issued,f shall
<br /> >'.. :_sic•
<br /> f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County
<br /> I ordinances, state laws, and rules an re tion'of the San Joaqu ocal alth District.
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<br /> 'APPLICANT'S SIGNATURE 1
<br /> 1
<br />'a. r
<br /> I � r
<br /> FOR DEPARTMENT USE ONLY
<br /> Fee Is Due: ❑ ANNUALLY w_ ❑ PER UNIT ❑ PER SITE ❑ EACH — ,
<br /> 1:1January 1 &Heceived By January 31 �f❑'
<br /> July 1 &Received By Jury 31
<br /> BASE y EXPLANATION BILLING REMITTANCE $ t .1 REMIT
<br /> DATE DATE _ REMITTED AMOUNT DUE i CHECKED
<br /> FEE ro ✓ O AMOUNT I n
<br /> LESS > +V}
<br /> PRORATION
<br /> " PLUS
<br /> PENALTY .
<br /> OTHER
<br /> OTHER +1 '
<br /> 1 Received by Date
<br /> Receipt No: Permit No �*;v =�
<br />�. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES I suance Date Mailed Delivered �
<br /> 1 Ol`E,HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 _"
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