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4 t ;Appll�ct;a! sWIIIBe Piocessed When Submitted Properly Completed..Be Sure To.Sign.The Applications { <br /> APPLICATION <br /> ' y ( ENVIRONfMENTAL HEALTH PERMIT 'e) �i SEPTAG�E <br /> For No f <br /> y 1 L <br /> LIQUID WASTE <br /> Application hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) Address 9 <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> 0.a Business Telephone No. Emergency Telephone No.. _ <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ti( <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.r,0 PERCOLAZiO,N TEST <br /> R.S.or R.C.E. Name w i"._ R.S. or R.C.E. No. <br /> Test 1,pcationst Date/Time <br /> 4. SANITATION PERMIT'!. __ <br /> Job Address/Location r <br /> O nor Address <br /> SEPTIC TANK__'C] C_ESSPO6L EACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT t'� <br /> ERMANENT ❑ TEMPORARY ❑ NEW r REPAIR t' ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS`' For July 1, June 30, 19 _ r� <br /> Type Construction t Disposal Site t�- +� 4 <br /> No. of Units,''v Equipment Storag/Clean ing:LoCiatio l(s) <br /> 8. ❑ PACKAGE TREATMENT PLANT For.JuJy 1, -JuneQ <br /> Operator Name <br /> P Where Certifled <br /> - <br /> Plant Location <br /> Plant Caktity s No. Units.Served ' <br /> 7. ❑ kXUNDRY For July 1, -June 30, 19 <br /> SIZE: fl Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Aniount/Mo. <br /> ' <br /> ROM owner ortiCensedagent's sy <br /> eos ;r,:;cr,, . ch ermi isissu tl,l, <br /> IR suchrnannet as to become subject t ivory 1F�r.11 ti c ampee3sat c!;IL ,Yu Jr kill,,i;�„ f s f p 1 ha!I notemploy anypeigon <br /> _-r'Contraetor's hiring or sub-contracting 6israturo corlitle ..iov7ing: "i %�.�i�)'iilflt it-,the I t <br /> employ persons subject to workman's compensation laws of% liiolnia. -1 ;3Yi'E'r" 'I'•r,e c.the work 444ic.>this psrma is issued,I shall <br /> �. I hereby certify that I have epared this application and Sha�(t work III be done in accordance with'San Joaquin Count <br /> ordinances, state laws, an a and regulati s of the Sa J in Loca•I Health Dyistrict. <br /> APPLICANT'S SIGNATUREX� <br /> ) <br /> �% �' I- � •— �dSC��� ��Gct•cle.[' � 8•..25 y, <br /> `FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE I $ REMIT <br /> BASE EXPLANATION DATE REMITTED AMOUNT DUE CHECKED <br /> DATE <br /> 1 AMOUNT <br /> FEE �; ` <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER } 7- <br /> OTHER OTHER <br /> Received by Date Receipt No. Permit No. _ ssuan Date Mailed Delivered i <br /> APPLICANT—RETURN AtzL.COPIES rO ENVmONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bal 20W, STOCKTON,CA95201 <br />