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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTACE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> • T a802 LIQUID WASTE <br /> Application Is hereby made to car on business in the jurisdictional area of the San Joaquin Local Health Distric//t <br /> y Business Name (DBA)�1tl�Ylr<1QCh 0 P[QL Address 5;;,-31Q)&�k`m� <br /> a Owner Gl�i'1 r -4.i�Y1�'�'Z:h Address ��� <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> Ci/�O/' <br /> L Applicants Name (Print r 610 Date tie ��, <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. 0 PERCOLATION TEST A4, <br /> R.S. or R.C.E. Name 6L" ul�nheiCLi R.S. or R.C.E. No. jZb3 �.1 <br /> Test Location <br /> -7-2-0c) P I'C.Y✓L4 Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address C <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ 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: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homs owner or licensed agent's signature ew flea the wowing;"f certify that in the perf"ance of Me work for which this permit is issued.I shah not employ any person <br /> in such manner as to become Subject to workman's compensation laws of Cathfn:: a <br /> Oontraetor's hiring or sub-eontrac.fng Sigpature -Irtftie3 the fallowing. 'I certify that In the,performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensation 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, arid'rules andegulations of the San Joaquin Local He th District. <br /> APPLICANT'S SIGNATURE X <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 /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS NVIRONMEN <br /> PENALTY <br /> I <br /> OTHER <br /> OTHER <br /> Rec d by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> PPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 <br />