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y Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ! APPLICATION <br /> (For Non-Transferable Revocable,and Suspendable) + <br /> -� ENVIRONMENTAL HEALTH'PERMIT SEPTAGE <br /> I' LIQUID WASTE <br /> Application ' reby made to car on business in the jurisdictional area of t San aquin Local Health Dist ictus, <br /> CFO Business Name (DBA) FZ <br /> a Owner , - it z Address �d, pjJ <br /> Address <br /> Z Firm Partners, Addresses and Teleph n J Numb rs <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. w <br /> L Applicants Name (Print) y ' <br /> Title = Date <br /> Please check Applicable Category(1-7) and Fill in the Required`Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I f"' � '''0 '• V r` 1' <br /> 'For July 1, �June 30;19 —° Disposal Sites -. <br /> Description(Make/Yr., Color) <br /> Serial.No. <br /> Capacity CAL. License No. CAL. License Renewal,No. <br /> Gal., Weights & Measures No. <br /> Equipment Parkin Address <br /> ` <br /> g Add,. ' <br /> 2. ❑ PUMPER YARD <br /> For July 1. June 30, 19 t� Y <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored I <br /> 3. ❑ PERCOLATION TEST <br /> ,R.S, or R.C.E. Name R.S. or R.G.E. No. a rr <br /> Test ocation Test Date/Time <br /> 4• SANITATION%PERMIT t <br /> Job Addr s/Location Ll <br /> Owner r Address <br /> .❑ SEPTIC TANK ff❑ CESSPOOL ❑ LEACHING FIELD 0 SEEPAGE PIT- .r❑ PACKAGE PLANT <br /> PERMANENT '❑ TEMPORARY ❑ NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30'19- REPAIR OTHER 'DfI u �D. <br /> Type Construction.' rt--• Disposal Site - r Q t <br /> No. of Units <br /> Equipment Storage/Gleaning Location(s) <br /> 6. El PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified r <br /> Plant Location -' "` , <br /> t <br /> Plant Capacity ' No. Units Served <br /> 7. ❑ LAUNDRY F0`r'July1,—June 30, 19 # <br /> SIZE: El Less Than 1,000 5q. Ft.,< More Than 1,000 5q. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.Homa �f <br /> in <br /> mirnrorticellsad egr�nbje it to wjecerdfiesrl,a following:"I certifyy that iRthe.performance of the work tat-w;lich this permit is iSsued,fshallnatesn Ifl as k <br /> in such manner as to become subject to w3rlcman s compensation taw;e+Cafifrr;;i2": P employ y person, <br /> emplayContraper•s s subjr er workman'sctin, ��s+tiQn l r certifies thF oflewin I seri'y That lithe portorn aslc of file work far tgtlich t is'uermit is issued,i shale C <br /> etrtplayt rsons subject iD workman's c� pensatic�n la1ks of Califami I." <br /> hereby certify that 1 have prepared this application and-fliat the work will"be done in accordance with San Joaquin County 7 <br /> ordinances;state laws, and rules and gulati0 f the San Joaquin Local Health District. <br /> I r <br /> APPLICANT'S SIGNATURE_X <br /> _ - <br /> FOR-DEPARTMENT USE ONLY- <br /> Fee Is Due: 0 <br /> AN PER UNITj '` PER SITE ,❑ EACHReceive - <br /> ❑ January 1& d By January 31 ❑ July 1 &Received By July 31 <br /> .. - � BASEEXPLANATION BILLING REMITTANCE REMIT . <br /> )` (DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE s <br /> LESS <br /> ..PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> u <br /> OTHER <br /> Received by Date ' <br /> LI Receipt No. Permit No. Issua a Date Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES '"" Y Deli <br /> e' +..: �1601 E..HAZELTON AVE.,P.O.Box 20D9 STOCKTON,CA 95201 <br /> ji - <br />