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Applications Will Be Processed When Submitted Properly Completed. Be-Sure7a Sign The Application. <br /> APPLICATION <br /> + (For Non-Transferable, Revocable, and Suspendable) ! <br /> SEFTAGE <br /> ENVIRONMENTAL HEALTH_ PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin LocalHealth Distri t <br /> rn Business Name (DBA) Address <br /> a Owner L-r,- S 15 frS Address. <br /> 0 Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. , <br /> Applicants Name (Print) "A�A L F-S a k-T r- S - Title O w *AES- Date <br /> Please check Applicable Category(1-7)and Fill In the Required Information 4 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) rn <br /> For July'1, - June 30, 19 `k Disposal Sites, <br /> Description(Make/Yr., Color) l r— <br /> Serial No. I CAL. License No. CAL. License Renewal No. �9 <br /> Capacity Gal., Weights & Measures No. <br /> r <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.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Address/Location �� Shy rQ.6 O i- vs <br /> Owner %44ME-'S Address l& 5 C.r- D ATOC-E�TG <br /> 'SEPTIC TANK ❑ CESSPOOL 9 LEACHING FIELD S SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ,T NEW ❑ REPAIR ❑ OTHER <br /> 5. 11CHEMICAL TOILETS For July 1,-June 30, 19 ;' so,� <br /> Type Construction Disposal Site 1 LT x W h di�' <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 „- <br /> Operator Name i Where Certified <br /> Plant Location i <br /> Plant Capacity No. Units Served <br /> 7. '❑ LAUNDRY For July 1, -June 30, 19 y <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑I More Than 1,000 Sq. Ft. <br /> © DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home ownerorficanaedagenx'asigneturvicert;fiasthmfollowing:"lcerilfythatinfheperflirmanceotthen�arkforwhlchthispermitisissued,Ishallnotem :• y <br /> in such manrrer as to ttecome subject tb kvorkritan's compensation IAws of California.` <br /> c6pVtremplo Per'srsons hiring r7r sub-cenuocLir.;s sfgnatura certifies the fallawing: "1 Certify Haat in the performance at the.work for vrhi�'�,'•'�r„��;iS i;i�� �f` 5rali - ' <br /> employ persons supjf ct t0 workman's compensation laws of California.” <br /> I hereby certify that I have prepared this application and that the work will be done in actor nce wi San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.i lLp <br /> APPLICANT'S SIGNATU X <br /> FOR DEPARTMENT US�E�ON�Fee Is Due: ❑ ANNUALLY ❑•PER;UNIT ❑ PER SITE ❑ EACH 1 &Received By'January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING TTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE - DATE REMITTED - AMOUNT <br /> FEE �s 4 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> OTHER <br /> Received by opte I Receipt No. Permit No. Issuance Date Mailed Delivered <br /> -APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 . <br />