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Oe t-WLVsSCu vgoun �uuinuteu Yropirly L:umplewci. Ue Sure I jig i rIC Application. <br /> APPLICATION - <br /> (For 1. .-Transferable, Revocable,and Suspendable) SEPT,'-1GF <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 /> Jsiness Name (DBA) Address �>'�� si. /J;'f'?� Sc;�_r..r✓ <br /> I Address <br /> wner <br /> rm Partners, Addresses and Telephone Numbers <br /> Jsiness Telephone No. i Emergency Telephone No. <br />)ntractor Licence No. r <br /> oplicants Name (Print) _ ---: /Llrray7 Title C41- ZZE• -- Date /0y- <br /> ease check Applicable Category (1-7) and Fill in the Required Information <br /> ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />)r July 1, June 30, 19 Disposal Sites s <br /> ascription(Make/Yr., Color) <br /> arial No.+ CAL. License No. CAL. License Renewal No. <br /> apacity Gal„Weights & Measures No. <br /> auipmeni Parking Address <br /> i <br /> ❑ PUMPER YARD <br /> ar July 1; June 30, 19 <br /> o. of Vehicles Stored <br /> C), of Chemical Toilets Stored <br /> ❑ PERCOLATION TEST <br /> S. or R.C.E. Name R.S. or R.C.E. No. <br /> afsst Location Test Date/Time <br /> SANITATION PERMIT <br /> ib Address/Location�,a 3 L - <br /> i ` <br /> wner .L;37 e4/_ �%-/lJ .1'T Z`'. - - Address i.c►-�sn <br /> ( SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 'R SEEPAGE PIT ❑ PACKAGE PLANT <br /> ( PERMANENT ❑ TEMPORARY Q NEW ❑ REPAIR ❑ OTHER <br /> ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> ype Cori'struction Disposal Site <br /> io. of Units Equipment Storage/Cleaning Location(s) <br /> ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> perator Name Where Certified <br /> 'ant Location <br /> ant Capacity No. Units Served <br /> ❑ LAUNDRY For July 1,-June 30;19 <br /> ZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> DRY CLEANING, Chemicals Used/Amount/foto. <br /> Home owner orffcensad agent's signarure eert'lms-he following:1-cerMyth,:.t in±fleperforrnance of theworkfor which this permit is issues,I shall not employ any person <br /> in such manner as to becomes0jectto wordmun';cclnpo^Galion laws of Cahlnnlia," <br /> Cootraatoi s hiring or sub-contracting signature certiflos the following: "I certify that in the performance of the work for which this permit is issued,I shall <br /> employ Pcrsons subject to workman's compensation laws of Cahlnrnia:' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> f ordinances,state laws, and rules and regulations of the SaJoagt in Local Health District. <br /> e <br /> "PLICANT'S SIGNATURE —` �--- - <br /> UL <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER'SITE ❑ EACH, "•❑ January 1 8 Received By January 31 ❑ July 1 $Received By July 31 <br /> BILLING REMITTANCE 9 REMIT <br /> BASE EXPLANATION AMOUNT DUE CHE�_ �7 <br /> DATE' DATE REMITTED AMOtFEE l i , �_A � <br /> LESS (' <br /> PRORATION �. <br /> PLUS <br /> PENALTY - <br /> I OTHEH i <br /> OTHER <br /> I <br /> Received by Dale Receipi No Permit No. Issuance D e. Mailed Delivered <br /> t APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1801 E.HAZELTOk , .O.9ai 2009 STOCKTON,CA 95201 <br />