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t.. Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferabltev> hle, and Suspendable) SEETAGE <br /> ENVIRONMENTAL HEALTH.PERMIT <br /> LIQUID WASTE <br /> Application is,"by made to carryon business in the jurisdictional area of thejan Joa$uin Local H,palth District. <br /> y Business Name (DBA) 5 �� Nf .�l�.rt/C' Address 1`tss (�f fC •� -1 �T, /!/ �.S. j�J <br /> i Owner _. Address t <br /> 7 Firm Partners, Addresses and Telephne Numbe s <br /> aBusiness-Telephone No. `Af �. 9Za? Emergency Telephone No.. p <br /> Contractor Licence No. <br /> L Applicants Name{Print) Title - Date z <br /> Please check Applicable Category(1-7) and,Flll in the Required Information,, <br /> 1. 1:1 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) l <br /> For July 1, June 30, 19 Disposal Sites � <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. f CAL. License Renewal No. <br /> I <br /> Capacity Gal., Weights &Measures No. e <br /> Equipment Parking Address } I <br /> 2. ❑ PUMPER YARD <br /> r <br /> For July 1, June 30, 19 I <br /> No. of Vehicles Stored l <br /> No. of Chemical Toilets Stared <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E:No., <br /> - T <br /> Test L cation Test Date/Time <br /> 4. SANITATION PER IT <br /> Job Addr ss/Locatio <br /> Owner <br /> 1 Address \� <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELDSEEPAGE PIT El PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY 11g- <br /> NEW ? . REPAlil ❑ OTHER i <br /> 5. C1CHEMICAL TOILETS For July 1, -June 30, 19 4` y'e �_[ y`, I r ! <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/.Cleariing Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 4'' <br /> Operator Name r1 f- ° ' Where Certified <br /> Plant Location <br /> Plant Capacity No. Units,Served` <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 t <br /> SIZE: ❑ Less Than 1,000 Sq" Ft.,' ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Pomp owner orficensod e9ont'ssig natlire.eertifesthe toltowinc:"ItertilyyIhill inthepe-A mancer1ftheworkforvehichthispermit1sissued,!shallnot�empIcyanyper,:. I <br /> in such manner as t1)become mb}ect I tvorkman's compensation?aws of California <br /> Caretractor's hiring or s�-contrer..4ing sigrnture Certitles the following: 1 certily that in the performance of the work for t'rhiCh this permit iJissued,I sh,u!I <br /> employ persons Subject 10 wnrk[rall's cvrpers;,tiorl laws of cglifarlli�� <br /> I hereby certify that I have_OWe alred'thi"s`application and-that the-work-will be-.done in accordance with San Joaquin County <br /> ordinances, state laws, and es and revif ions of an Joa in Local Health D-istrict.- <br /> F ' t� <br /> APPLICANT'S SIGNATURE X r y <br /> 6 .. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITS ❑ EACH ❑ January 1 &Received By January 31 ❑ July l &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION 'BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE, _ —,:GATE REMITTED.. AMOUNT <br /> i <br /> FEE <br /> a <br /> LESS : <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER f <br /> Received by Date 1 Receipt No. Permit No- Issuance Date Maiied Delivered, <br /> APPLICANT.—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> F yT� <br /> �w/ <br />