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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable;Revocable, and Suspendable) SEPTACE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> - LIQUID WASTE' <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) •� Address 6 �C <br /> aOwner . % - . -'Z L c= Address <br /> J Firm Partners, Addresse and Telephone Numbers 1, v <br /> Q. Business Telephone No. • Emergency Telephone No.. <br /> Contractor Licence No. <br /> Applicants Name (Print) `. Titley 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 /> i <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 /> Test Location Test Date/Time <br /> 4. `7 1 SANITATION PERMIT - S <br /> t r <br /> Job Address/Location i � ' y I,74 _( .1i9 <br /> Owner 4 Address — C- <br /> SEPTIC TANK ❑ CESSPOOL 'LSACHING.FIEL--D 1:1SEEf AGE PIT 1:1 PACKAGE P T <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) t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> F <br /> Plant Location ' <br /> Plant Capacity --- �' No. Units Served <br /> 7. ❑ LAUNDRY; For July 1-, -`June.30,.1.9 <br /> SIZE: El Less Than 1,000-Sq. Ft,, ❑ More eTtian 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/AmOUllt/Ma., <br /> Homeowner or licensed egerit's signature certilksttw following:"!certify thaf In the performance of the work for which this permit is Issued,I shall not employ1personin s�rch manner as to become subject-to Itrerkiiian'scam;ensattnniac:aContractor's hiring or aub-con+r3eting sic :ui cergijes ;`s Toltowiny: 1 certify that in the performance of the work for which this permit is issued, <br /> employ persons subject to workmanS compensatlua law'S of Caliloriiia." <br /> I hereby certify that l have prepared this ppIicatiori-and,that-the work-will be-done-in�accordance with San Joaquin County <br /> ordinances, state laws, and rules an tions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> l FOR.DEPARTMENT_USE ONLY--I;.,.,..,,`y� ` <br /> Fee Is Due:!i] ANNUALLY 0 PER.UNIT ❑ PER SITE 13 EACH El January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE '$ AMOUNT DUE CHECKED <br /> DATE s- DATE REMITTED AMOUNT <br /> I s <br /> FEE <br /> t <br /> y ; { <br /> LESS <br /> PRORATION E <br /> PLUS - <br /> PENALTY 'f' <br /> OTHER <br /> OTHER - .� �� "i �? �'�'3 '� • ! k `' <br /> Received.by Date Receipt No. - Permit No. is,uance Pale Mailed Delivered I* •?, <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE.,P.O.Box 2009 STOCKTON,-CA 95201 <br /> ti <br />