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..Applications Will Be Processed When Submitted Properly <br /> APPLICAT'ION <br /> 1= (For Non-Transferable,Revocable,and Suspendable) SE4'TAGE <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> LIQUID WASTE alth District_ ! <br /> Application i made to r op�busy�ess in the iurisdictional area of the;San Joaquin Lo 'd 15111P <br /> /[) /� Address <br /> yBusiness Na BA)`, Address <br /> z Owner41 <br /> J Firm Partners, Addresses an Telephone Numbers Emergency Telephone No. - <br /> G ..,. . <br /> IL Business.Telephone No. '' <br /> . Date "• <br /> Contractor Licence No. µ Title <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> �• ❑ PAMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> ForJuly 1, <br /> une 30, 19.. _ Disposal Sites <br /> Description(Make/Y i, Calor) CAL. License No. CAL.-License Renewal No. <br /> Serial No. <br /> Capacity Ip, Gal..Weights&Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD — — <br /> For July 1; 1'une 30, 19 H <br /> No.of Vehicles Stored r <br /> No. of Chemical Toilets Stored r <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. No. <br /> i -j, <br /> R.S. or R.C.E.Name <br /> Test Date/Time i <br /> r <br /> I Test Lcation �a <br /> A. SANITATION PERMIT w <br /> Job Address/Location Address <br /> Owner 11 LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> 1 '❑ SEPTIC TANK i� ❑ CESSPOOL EPAIR ❑ OTHER <br /> 1133 PERMANENT i ❑ TEMPORARY ❑ NEW ✓, <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 1Disposal Site <br /> Type Construction <br /> No. of Units I Equipment Storage/Cleaning Location(s) K <br /> .6• ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name ,u r <br /> l Plant Location A� No. Units Served 4 <br /> Plant Capacity `Il <br /> -t x <br /> 7. ❑ LAUNDRY 4 For July-1, -June 30, 19 ' <br /> SIZE: ❑ Lessj Than 1,000 Sq. Ft., ` ❑ More Than 1,000 Sq. Ft. + <br /> ❑ DRY CLEANING, Chemicals Used/AmounVMo. _ <br /> I � <br /> Hneneowner orlfcensedahert'ssiQnRtU*ecc�tlf3�att+ tolfaw4rig•"IceR•yiha!?n the perfarm3lta:eaf't"�orklorwhichthisperWmitisissue6,1shal1notemployanyperson <br /> r in such mariner as to become subject Iii workman's cu MP0.9alion lags of Gafiloi'rti=•'` <br /> n atuge ceerities the fatiovving-,"I certify that in the;performance of the t;flrk for which this permit is issued,f shall <br /> I convactar s hmr%g or sub-contracting'.. art , <br /> employ persons�sabject to workman s compsrLsatron laws of California."" <br /> 1 hereby certify that 1 have prepared re thisapplication <br /> t and that ihe work <br /> Joaquin Local Health be <br /> one District. <br /> ccordance with San Joaquin County <br /> ordinances, state laws, and rul 9 <br /> APPLICANT'S SIGNATURE X <br /> dd!! 7 " FOA DEPARTMENT.USE ONLY <br /> I� REMIT <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE EACH ❑ January 1 &Received E3y•January 31 July 1 8 Received By July 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> AMOUNT <br /> BASE EXPLANATION DATE DATE REMITTED <br /> FEE �� -H <br /> LESSi�' <br /> PRORATION <br /> PLUS c <br /> PENALTY <br /> OTHER I�F <br /> OTHER 9 _ <br /> III i 3 l0 7 8� <br /> Delivered <br /> l,i 'Receipt No. Permit NoCA 95201 <br /> Received by CA <br /> - 1601 E.HAZELTON AVE.,P.O.Box 2009 sTOCKTON, <br /> APPLICANT—RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERM177SERYICES <br />