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a6 Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION 'S <br /> L (For Nan-Transferable,Revocable,and Suspentlable) <br /> ! ENVIRONMENTAL HEALTH-PERMIT SJ PTAGE <br /> 1 LIQUID WASTE " <br /> Applicati n .111shereby pade to carry on busing in the jurisdictional area of th an Joa in Local Health Distric <br /> F8 <br /> Business Na a (DBA) G7l 1� 1,t�1 Ad ress �� <br /> aOwner Address 1 t 1£ h R <br /> J Firm Partners, Addresses and Telephone Numbers a ,- <br /> aBusiness Telephone Na. q - Emergency Telephone No. <br /> Contractor Licence No. M <br /> L Applicants Name (Print) Title <br /> Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1'tlt� p - <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June 30, 19 :.Disposal Sites - 1 <br /> Description(Make/Yr., Calor) - - - - <br /> Serial No, i CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. ._...0 <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD t y r y For July 1, June 30, 19 <br /> No. of Vehicles Stored T <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 /> Te <br /> s Location - ; ' Test Date/Time <br /> 4.--M-SANITATION PERMIT t e + <br /> 1 Job Address/Location <br /> Owner Address i <br /> "SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT, ❑ TEMPORARY NEW r <br /> - REPAIR ❑ OTHER ' <br /> 5. ❑ CHEMICAL TOILETS For July 1, June 30, 19'' <br /> r - <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) a [ ki <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19' ` <br /> Operator Name " ' <br /> Where Certified . <br /> Plant Location <br /> Plant Capacity r "` - t,.-* No Units Served , <br /> 7. ❑ LAUNDRY, Fo-r July-1 -'June 30,,19,4' <br /> SIZE: ❑'Less Than 1;004 Sq::Ft.,.m❑fMore.Than 1,000-Sq.`Ft. ' <br /> ❑ DRY CLEANING,'Chemicals Used/Amount/Mo. <br /> Home owna�orlicensed ar�en;'cs9g�A1sra1erMg2thofrA;owir-w"Icertlfyiat ;l,h p9,f;lrm'lnceofLImwork forw4ichthis ermitisissued,Ishalfnot employ any perso-1 <br /> in such manner as tb become subject to irrarkm ar s car pe.lsatien twrs al t alnnriara p <br /> Contractor'spope,-so hiring or sub eontrsctin$ sigicaxure certes<cs�o fctloviiiiig-,',I t:ertdy t;,at in the performance c;the work for which f9;;�permit is issued,I shall <br /> employ persons subject to workman s cor;�pensatlon taws of Call crnia." <br /> I hereby certify that l have prepared this"pplication and,that the work will be done in accordance with San Joaquin County �A <br /> ordinances state laws, a d rules and`r u to f+the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> s , <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY El PER UNIT PER SITE " ❑rFACH_` ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 9.`+ - ` BICLING.,,,'"'t REMIT <br /> erT�,J. 4 `BASLk EXPLANATION`+ �h ` REMITTANCE $ AMOUNT DUE CHECKED <br /> a ' DATE DATE, REMITTED l <br /> �y C� AMOUNT <br /> � FEE.LESS <br /> t <br /> PRORATION <br /> PLUS <br /> PENALTY / „� 'VIS ' ti •. R. .1 <br /> l`.. <br /> OTHER <br /> OTHER 1 (� 1 <br /> l✓ <br /> Received by 'pale Issuance Date Mailed pp <br /> - _ N 4� -Re�eipt No y' 4 Permit No. elivered <br /> APPLICANTL RETURN ALL COPIES TO; ENYIRONMENTAt HEALTH-PERMIT/SERVICES - 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201 <br />