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APPLICATION <br /> r Non-Transferable, Revocable, and Suspendat SEPT <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is.hereby+crade to carry on business in the jurisdictional area of than Joain Local Health Distric - <br /> fCI rt l _ <br /> Business Name (DBA) _111Address <br /> i <br /> i Owner V Address <br /> U Firm Partners, Addresses d Telephone N mt l <br /> Business Telephone No. i/�^i�a � Emergency Telephone No.�� a <br /> Contractor Licence No. - ^• - <br /> L Applicants Name (Print) ` — Title Date fL <br /> Please check Applicable Category (1-7) and Fill in the Required Information �J <br /> 1. I] PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Makes Color) - W <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. 13 PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. 0 PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S.or R.C.E.No. <br /> Tes Location - Test Date/Time <br /> 4. SANITATION PERMIT 11 ) y ,• ��• ,� <br /> Job Address/Location <br /> '. <br /> Owner Addre���srrr+++s��crrr - <br /> --SEPTIC TANK CESSPOOL LEACHING FIELD "SEEPAGE PIT PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW REPAIR OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site -. <br /> No. of Units Equipment Storage/Cieaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified - --� <br /> Plant Location - <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY Fot-July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 13 DRY CLEANING, 4hBrnicals Used/Amount/Mo. <br /> Hrme owns eeani agent's s!gna".ur a cart.:3stba enlfowRw:"I r ortily'hat in:hp peI{nrm3RCeof LhBy+ork.farxhich this permit is issued,l shall not employ any per; <br /> in such manner as to become subject to workmen's co:are::r aticn laws 0Califort:ia' <br /> Contractor's hiring or subconerecttng signature certiftes the following! J certify that in the pnformanco of the wo:k for w4ich!1 ?rri is issued,I shall <br /> employ Persons subject to workman s cornpensafian laws of Califcrnia:' <br /> I hereby certify that I have prepared this pplication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state Jaws, d rules and r u do f-the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X �1! 4 / <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 6 Received By July 31 <br /> ZIONREMITTANCE s REMIT <br /> BASE EXPLANADATE REMITTED AMOUNT DUE CHECKED <br /> yy AMOUNT <br /> FEE rq <br /> LESS <br /> PRORATION PLUS d <br /> PENALTY s .{ G. 2J <br /> OTHER 7_ <br /> OTHER <br /> Received by Date Receipt No. Permd No. Issuance Dete 56fivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />