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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. "y <br /> io7. APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> • ENVIRONMENTAL HEALTH PERMIT ENVIRC�111�t OHEALTH <br /> LIQUID WASTE F ERM11 f SERVICE$ <br /> Application is hereby made to car on business in the jurisdictional area of the San Jo g4in Local Health District <br /> OF Business Name (DBA) -t3'I� y j l tt-Ei 7- 7-19-(a AddressVi �ft`S"t L <br /> a Owner `DIr r ki Pi 1 ZC1 Address <br /> J Firm Partners, Addresses and Telephone Numbers 6-117-r-3Bi bac C?Li rri G- <br /> 5. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. _ <br /> a PP (Print) - �. Date <br /> �Applicants Name Print tle <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. Y PERCOLATION TEST <br /> R.S. or R.C.E. Name ` R.S. or R.C.E. No. °9p'{' <br /> Test Location (- Test Date/Time t 1 ) ? —A 1 Z <br /> 4. 11 SANITATION PERMIT IC y' 'Linz_ <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 0- PERMANENT ❑ 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: ❑p�Less <br /> yJThan 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY Cit+,'p'fy ?""G� PIRfi2C�?Ci5etf�Amtwnt�MQ,:t,' <br /> r .-iorr n.' cr, I that in the performance of the work for a hich this permit is issued.Ishal r„it employ any person <br /> Canir�at� s comp6n atlaws of California.” <br /> employ(;utg! "nature certifies vie fr,flowing: ­I certify That in;hc p,,; .;�anra li;c.v3rk for which this pe:mit is issued,I shall <br /> -•.r .anon laws of California." <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,0 rules an regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X � F' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BAaSE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE -- <br /> r <br /> LESS <br /> PRORATION <br /> PLUS It <br /> D l <br /> PENALTY <br /> OTHER f ,/ <br /> OTHER <br /> RtPLICANT—RETURN <br /> d by Receipt No. Permit No Issuance Date Mailed Delivered <br /> 4ti�/? <br /> ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />