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APPLICATI'Q111 - - �' ----"- - <br /> r Non-Transfei'eble'-RevOcable,'and Suspendab <br /> ENVIRONMENTAL HEALTH PERMIT4 SEPtAGE <br /> f uQulo WASTE . <br /> Application is h ebyade onr on mess in the,jurisdictional area of theS J <br /> I Business Name (DBA) _P gain c IH is t <br /> aOwner Address (� <br /> 5 Firm Partners, Addresses and Telephone Numbers Address <br /> Business Telephone:No. <br /> Contractor Licence No. Emergency Telephone No. ; <br /> 'Applicants Name (Print) •. <br /> ti Please check Applicable Calegory.(1-7)and Fill In the Required Information Tit je Date 4 <br /> f 1• ❑ PUMPER VEHICLE PER REGISTRATION(FOR EACH VEHICLE) s <br /> For July 1, June 30_19 <br /> Description(Make/Yr., Color) -_,Disposal Sites. <br /> I <br /> Serial No. CAL. License No. <br /> Capacity'- CAL. License Ren <br /> r Gal., Weights &.Measures-No. ewal No. f r` <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD <br /> ., <br /> For July 1 June 30, 19. ' .. `t 1 <br /> No. of Vehicles Stored F' <br /> No. of Chemical Toilets Stored <br /> 3• ❑ PERCOLATION TEST <br /> R.S.or R. Name <br /> Test L at R.S.or R.C.E. No. <br /> 4. JZ SANITATION PERMIT Test Date/Time <br /> Job Address/Location <br /> Owner tr g g -P i <br /> ❑ SEPTIC TANK. ❑ LEAddress l G '.A <br /> CESSPOOL. . ACHING FIELD.. 0 S � <br /> ❑ PERMANENT *_ ❑ TEMPORARY + PST•--.,.❑ PACKAGE PLANT <br /> EW-" REPAIR I ❑ OTHER <br /> 5• ❑ CHEMICAL'TOILETS For July 1, -June 30 19 <br /> 1 <br /> , r <br /> Type Construction i <br /> Disposal Site. <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6- ❑ PACKAGE TREATMENT PLANT For July i,- r � <br /> June 30, 19 <br /> Operator Name I <br /> Plant Location where Certified <br /> Plant Capacity <br /> 7• ❑ LAUNDRY For July 1,-June 30, 19_.�� No. Units Served <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 5q, Ft. E <br /> DRY CLEANING,Chemicals Used/Amount/Mo.- <br /> 14"M <br /> sed/Amount/Mo, <br /> Hotneo'Aw"tticensedagent'ssignat�seseri#feathefeIfolrr trrrt'1 fha h <br /> in such <br /> In as to beCvrne suh}ect to workman's ccm �n at,e ' 1 ' e performance of the work fat wh ch this permit is issued,t spa; (� <br /> Corrt*aetoes Airing or sub-contm,tipg sEy 1�t ;0 ^Ere a s rh �' i tompt�� <br /> PIoY persons subject to workman's ea repo lsatiorl laws of t d 1, i,,a.'.ilow ��„ Ce'tiiy<hat it file performance cf tl.�v�ark for which this�er3.st i <br /> s v ;. ssued, srla,,41 <br /> I hereby certify that I have prepare 'this a plication and thaYlhe work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules r tions of the Sa "Joaquin Local Health District. <br /> APPLICANTS SIGNATUREX <br /> FOR DEPARTMENT USE.ONLY <br /> Fee Is Due; ❑ ANNUALLY ❑ PER-UNIT ❑ PER SITE <br /> _ F-1 EACH 13 January 1 6 Received By January 31 ❑ July 1&Received By July 31 <br /> BASEEXPLANATION BILLING REMI :] <br /> TTANCE g t4EMiT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE e. f� AMOUNT <br /> LESS <br /> PRORATION / <br /> PLUS 1 <br /> PENALTY 1U <br /> OTHER �{ <br /> OTHER "I P <br /> Received 6y pate � ! k= � � <br /> Receipt No- Permit N0. <br /> APPLICANT RETURN ALL COPIES TO; ENVIRONMENTAL HEALTHH PERMIT/SERVICES Issu nce Q e Mailed Delivaretl <br /> 7601 E.HAZELTOM AVE.,P,O.Box 2009 STOCKTON,CA 952 <br />