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Applications Witt Be Processed When Submitted Properly Completed. Fie Sure To Sign The Application. <br /> APPLICATION <br /> Non-Transferable,Revocable,and Suspendable) SEI'TAGE <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 /> ,FBusiness Name (QBA) X4 /c Address A FwL/ <br /> I.-Owner l� Address <br /> a J <br /> Firm Partners, Addresses and Telephone Numbers <br /> d Business Telephone No. Emergency Telephone No. <br /> K <br /> Contractor Licence No. <br /> Applicants Name (Print) �,�� C . %�SL+17 Title e/u�;Ykee+r Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <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. Cff PERCOLATION TEST <br /> queer R.C.E. Name fG R$-e;R.C.E. No. /5fG �5F <br /> Test Location s 4 .aL/}C4� I'�'1 Test Date/Time <br /> 4. ❑ SANITATION PERMIT Sel— 3 7 <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 0 TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <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 /> Plant Location -- -- <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Horne owneror licensed agent's signature the fo!ro+wkw:"I Certify that lithe performance of the work for which this parmit is issued,l shall net employ any person, <br /> in SUCK manner ds to become su*..ct 10 wotkmiin:•1:onopen"'Atirm faVr!�n1 C.'atifttrTlia.. <br /> Contractor's hiring or rub-cantmeling 4gnatuse cer6lirs the following: I certify that in the performance of the work for which this permit is issued,i stAll <br /> employ persons subject to workmai's compessallon laws of Calif fnia." <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY 0 PER UNIT ❑ PER S1TE © EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED++fi�rr AMOUNT <br /> FEE 12 7 r i1D�r7r O r6^ 7 �vaav <br /> LESS <br /> PRORATIONPLUS <br /> ! <br /> PENALTY el <br /> OTHER l <br /> OTHER <br /> Recei ed Dale Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />