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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> _ APPLICATION
<br /> s y (For Non-Transferable; Revocable,'and Suspendable) S�p3AGE
<br /> k ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID'WASTE
<br /> Applic Ion is h eby made to carryon lousiness in the jurisdictional area Of San aquin Local Health District. ,
<br /> Business Name(DBA) � �g15- �,r '�.�
<br /> a Owner Address -
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> m Business Telephone No: +� �_ - � __ Emergency Telephone No
<br /> Contractor Licence No.
<br /> LApplicants Name (Print) I Date
<br /> Please check Applicable Category (1.r7)-and Fill in the Requ1. ired.lnformation rte'
<br /> 1. 11PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) a T r'
<br /> For July 1 June 30, 19 ; Disposal Sites
<br /> Descriptio6JMalie/Yr'jColor)}'
<br /> Serial No. '� CAL. License No. CAL.License Renewal No. s
<br /> i `' } _. 9
<br /> Capacity � � '�� GaI.;�Weights &Measures No.,-- -� d•—�-----� w ----+ •¢
<br /> Equipment Parking AdAel,',—.: f` '
<br /> 2._❑ P,UMP.EF}..YARD
<br /> 14F r July 1, f `' `� June 30f 19�' 1 1. '
<br /> N&,of VehlclesiS.tored-" wx`'� .tip ..� ; '� -e—Ir i
<br /> .No. of Chemical Toilets Stored
<br /> 3. ❑ PERCOLATION TEST
<br /> 4 R.S. or R.C.E. Name R.S. or R.C.E. No.
<br /> Test Location Test Date/Time
<br /> 4. VSANITATION PERMIT
<br /> Job Address/Location
<br /> 'W0 ner Address b .t `
<br /> SEPTiC TANK. ❑ CESSPOOL '-C LEACHING FIELDSEEPAGE PIT 13 PACKAGE PLANT `"it V
<br /> XPERMANENT 11TEMPORARY i ❑ NEW REPAIR 11 OTHER a � )
<br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30 1.9
<br /> Type Construction Disposal Site
<br /> No. of Units Equipment Storage/Cleaning Location(s)
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30,s19'-4 'Q 4
<br /> Operator Name t 4 t' Where Certified ; '
<br /> 'Plant Locationt� �i1r i ." s ,:w r'.°� � , .► --' O
<br /> Plant Capacity `'`f� 1 N nits�erved""'" R `! 1 ' ! " 1
<br /> 7. LAUNDRY For July 1, June 30,',19 ,
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,. El More Than 1,000 Sq. Ft.
<br /> s L�'
<br /> 0 DRY CLEANING, Chemicals Used/Amount/Moi, a "t s.�g` {t
<br /> _ t
<br /> Ho"ownsrorticensedageot'ssignature ceffiiestWfollowv* #f?rt"V ir' .ha;_u�rre-.^-ceaftheu4or,<tc hichthiSpermiii5issued,tshzitk�otemp3oy nype_en
<br /> in such manner as la become,subject to workmalft compen5l'iolm
<br /> Contractors airing or sub-contracting,signature cartif:e r iv,tcltpiY r g' I a ?> IIS that s':ar i �C t L'Ie 1,101 k for which this perntit.is issucJ,I111ar
<br /> employ persons subject to rvorkrriari s compensation:avis of ciliforl`:ia.'
<br /> " I hereby certify that I have prepared this application and at the work will be done in accordance with San Joaquin County-' t
<br /> ordinances, state laws_, and s nd regula ' ns of the SV Joaq 'n Local Health District.
<br /> APPLICANTS'SIGNATURE X r
<br /> CD
<br /> FOR DEPARTMENT USE ONLY
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Lceived By July 31
<br /> E° } REMIT i
<br /> BILLING REMITTANCE $
<br /> BASE :EXPLANATION AMOUNT DUE ..,CHECKED
<br /> 1T i DATE DATE REMITTED AMOUNT
<br /> f ,
<br /> FEE �y
<br /> LESS }
<br /> PRORATION ,;-
<br /> PLUS ' S
<br /> PENALTY
<br /> s
<br /> OTHER
<br /> OTHER ._ - P++d'-- ,....:.w.e....i.r...,... �.,.i �....�.. ,.» :YAM ,.�....�.. .� ........,,..... 1, 1,1,1,!.-:...r...-..d.Y...-.... .,.,,�....,..�...a...�.,..i
<br /> PIP IN
<br /> r• r-
<br /> ..�.. _.,.____:_ ...�.�..�...^..M_!1,1,.1,1,�._s.. .�.»;.�..�.,•.,....:...:���-��q �....��.� _ ..._
<br /> Received by Date Receipt No, Permd No. Issuance Dat Mailed Delivered
<br /> - APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Boa 2909 STOCKTON,CA 95201 -
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