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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable' Revocable and Sus Pendable) SFPTAGF <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on busines in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) s 9- � T/ r}�„ _ 1 Sola Addresses/'s G. &C Z&.4�2 JD-A=44", <br /> aOwner Address. <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 4 Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) ,�f� c�iAE� /—�.R2I/C Title C41 �� ofv� Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information p� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C\1! <br /> For July 1, June 30, 19 Disposal Sites I <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. ❑ 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. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner gnest' G�`..°,��c��f,di Address _/6/06_/7yi-t7L�+tr� �'lZ. <br /> ❑ SEPTIC TANK Ca CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 i <br /> Type Construction Disposal Site t <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> a <br /> Plant Location <br /> Plant Capacity No. Units Served �t <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE; ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. � <br /> ❑ DRyj �hemicals Used/Amount/Mo. A i <br /> � �lrbnll�tlsflrr*4 ;g",tt+rar,rrt7figsthQfa;[aw[rr�:"I V'rtif}�that in±he{zerformance of the vlt�rk fprtivhich the permitis€sStasd.IshaN n t`� <br /> In SUCl11R3R±fer as 19}18i;t1il1�$UIIf 1(t tta L`Ip; 1;3;1€1`S 1 6,^pail i3t{ ;!I?Kg i $I{fthAt i',` <br /> �onaactnr's hlrlrsq or slrb-ccntraetina rl�natlsre ces?ifiAg sh•_ takuwiny: "I certify that in the performance Of the tis{ork for which this permit s Issued, shall ersOtl \\\ <br /> i enrytay�ersbns Su4jeei i4 trmkmeri S comyensation laws ai cal,tclljita," <br /> I hereby certify that I have prepared this application and that the work will be done-€n-accordancewith Sart Joaquin County <br /> ordinances, state laws, and rules and regulations of the San aquin Local Health District. <br /> APPLICANT'S SIGNATURE X k <br /> FOR DEPARTMENT USE ONLY I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT , <br /> ++ y r <br /> FEELESS <br /> PRORATION <br /> PLUS V '� f ih/r✓ + <br /> PENALTY <br /> OTHER f /_ <br /> OTHER GC <br /> Received by Date Receipt No. Permit No Issuance Date Mailed red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />