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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 0APPLICATION <br /> 8803 (For Non-Transferable, Revocable, and Suspendable) SFPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) Boun7boc17 f48 07 za Address3� �`� <br /> i Owner Wen SciumbGc/7 Address Some <br /> Ja p Te�r� <br /> Firm Partners, Addresses and Telephone Numbers 8"7n Same <br /> aBusiness Telephone No. 36A 1)b 1$ Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Glen .T Brlumbach1nr,10 /7Y0IQWeRitle R.C•6, 126 8 Date 3 —11M <br /> Please check Applicable Category(1-7)and Fill in the Required Information Ci v1 Engr <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 n <br /> 3. 1� PERCOLATION TEST <br /> R.S. or R.C.E. Name blen 1 13pLimbad7 R.S. or R.C.E. No. X685 <br /> Test Location Jain — Test Date/Time <br /> 4. ❑ SANITATION PERMIT <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 /> in such annex lfc+o Z.49OW"sio�e�aseUMonMtMlewiw��'7oeeNtvtlratinfheMriermar>foeoflMNMle%rwMtAAds0ennKieisseed.IsWnotemp"myperson <br /> in such manner as to become subject-to wmRmari s compensation laws of C2firrrt;1, <br /> Conasotor's hire or sub con""ting dynsturs ceraRes ehe fouow;np; 1 certify that in ft performance of of the work forwlach this permit is issued,I shall <br /> employ persons subject to workman'scompensation laws of Calirowailw." <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Recei by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> A ICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />