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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application <br /> APPLICATION ►t� �Q��Y <br /> (For Non-Transferable, Revocable,and S able) SEPT/`•,r'=—' ���/ <br /> ENVIRONMENTAL HEALTH PERMIT ,r- <br /> LIQUID WASTE <br /> A plication 's h r b to car• si e s i 1 is 'c n I rea of the San Joa in Local He Ith D trw t <br /> yBusiness Name DBA � ry ddre <br /> I`_ Owner ' dress `'` r <br /> a <br /> J Firm Partners, Addresses and TelephonQe umb s Z3�1—47'6)8 <br /> I Business Telephone No. Zig- r � Emergency Telephone No. <br /> a <br /> Contractor Licence No. _ <br /> L Applicants Name (Print) °G �Y� Titled N��" 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 <br /> 3. PERCOLATION TEST / <br /> R. . or R.C.E. Name _ '�+ R.S. or R.C.E.No. F 15� <br /> Test Location s 2 IJ- <br /> Test Date/Time + �' _ �'- " T �l <br /> 4. ❑ SANITATION PERMIT .77 tk / <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 /> Horne owneror licensed agent's signature certifies the following:"I certify that in the performance of the work far.vhich this permit is issued,I shall not employ any person <br /> in such manner as to become subject to>rorkmar scompensation taws of California <br /> Contractor's hiring or sub-comracting signature certifies the following: 'I certify that in the performance of the work for which this perrtit is issued,I shall <br /> employ persons subject to wor%man's compensation laws of California." <br /> I hereby certify that I have pr Bred th' appli n n that the rk w' a done in ac rdance with San Joaquin County <br /> ordinances, state laws, a s and ulatio s f an Jo a ealth District. <br /> APPLICANT'S SIGNATURE X AA Ir <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 /> BILLING RE ITTANC $ REMIT <br /> BASE EXPLANATION DATE TE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE s C <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—R URN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />