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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> nr .f (For Non-Transferable, Revocable, and Suspendable) <br /> SEFTAGE <br /> ENVIRONMENTAL HEALTH PERMIT_ <br /> LIQUID!WASTE <br /> Application is hereby made to carry on business in the"urisdictional area of th San Joaquin Local Health District.., . <br /> T Business Name {DBA) « b Address <br /> .I <br /> z Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Emergency Telephone No. <br /> a <br /> -jz Contractor Licence No. .. - <br /> � <br /> Applicants Name (Print) �Tfr�l� �T=R .. Si]_1.4,x_.. Title �, � Date y Z- <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. - t C-. CAL. License Renewal No. <br /> e ." + .. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 1 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E.No. <br /> q <br /> Teon .� Test Date/Time <br /> t cation <br /> a. SANITATION PERMIT <br /> Job Addrtss Location <br /> Owner LL SE,r Address <br /> © SEPTIC TANK ❑ CESSPOOL M_LEACI-IING FIELD .SEEPAGE+4:P ❑*OTHER <br /> PACKAGE PLANT, <br /> �ERMANENT ❑ TEMPORARY 11 NEW tREPAIR � ❑ <br /> r <br /> 5. ❑ CHEMICAL TOILETS For July 1--June 30, 19 r f� <br /> N. v <br /> Type Construction i '-D,isposal Site <br /> No (l,. of Units Equipment Storage/Cleaning Locations) --M-�'A <br /> l6. ❑ PACKAG E TREATMENT PLANT For Jul 1,-June 30, 19- . D" Y- <br /> Operator Name Where Certified <br /> Plant Location+,: . .., f -• —wr- <br /> .r, f 1 <br /> Plant Capacity .'-i - *' -' No. Units Served <br /> I7. 11 LAUNDRY For July a,-June 30,.19 <br /> SIZE: © Less Than 1,000 Sq. Ft;" 0,More Than'1,000 Sq`'Ft. - <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Homeowner.orficansndogetit'ssigoat�yreccrlif�as eialtos+rind:`ImrtifVthat!iy?,'reverfj)lnenefgf.1f+Q:vorkior:+rtrichthis permitss=.ssued:Ishaflnot employany persGn <br /> in strch manner-as to- ecmrle;object to!vcrltlrian"s rnr nGati n t€ws ni t ai Tc +� <br /> Contractor's.hiring or sub-contsac,6ng the? folio as+7 r :i`;^thst isr tr a i4e,tcrmanee cf the work for which 1bii-pe,mit•it-issued,I shall <br /> employ persons subject to wcrkmari s corrpwn a icn lavrs a;Cairfnrnia." <br /> I I hereby certify that I have epared this application and that the work I e done in accordance with San Joaquin"dounty <br /> ordinances, state laws, r le and regulate of the S aquin al ealt istrict. t i <br /> �APPLICAN:T'S SIGNATURE X <br /> i <br /> FOR DEPARTMENT USE ONLY. <br /> i Fee IS Due: ❑ ANNUALLY El PER UNIT, ❑ PER SITE•+ ..❑•EACH ,❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> { r{y f REMIT <br /> BILLING- REMITTAN <br /> 1 BASE EXPLANATION CE AMOUNT DUE CHECKED ' <br /> 1 .. - .. DATE -`DATE ' ,,. REMIt$TTED AMOUNT <br /> i FEE <br /> LESS <br /> PRORATION' .. .tee, .ti.•._ ... - rr. r r <br /> PLUS •� .....-'i +.-�.. °� �. J '""`e x'^! s a [ -9..:4 - ,.. . <br /> - <br /> -PENALTY .,..vim, ..►. ., r -. Y L „ - - <br /> t ( OTHER <br /> OTHER <br /> 53 , 2- <br /> .I Received by Date f 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,C 1 ` <br /> - s' <br />