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Applications Will Be Processed When Submitted Properly Completed.BeSureTo 5ign �ne <br /> 1 i•• <br /> APPLICATION <br /> (For Non-Transferable;Revocable,and Suspendable) SEPTA. <br /> ENVIRONMENTAL HEALTH-PERMIT 1 s > , er <br /> LIQUID WASTE ::+ <br /> Applica ion 's hereby ade to carry n business in the'urisdictional area of the San Joaquin Local Health District <br /> ,F Business Name (DBA) <br /> p e Address �` <br /> � Address <br /> a Owner <br /> J Firm Partners, Addresses and Telephone Numbers W <br /> C1. <br /> Business Telephone Noy - _ Emergency Telephone No. <br /> a Contractor Licence No. <br /> Applicants Name (Print) <br /> 1 11S Title Date <br /> Please check Applicable Category (1-7)and Ill in the Required Information. ; �w <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) U <br /> For July 1, <br /> June 30, 19 Disposal Sites - <br /> Description(Make/Yr., Color) CAL. License Renewal No.. <br /> Serial No. CAL. License No. - <br /> Capacity • Gal., Weights &yMeas ures No._ _ <br /> Equipment Parking Address `"" <br /> 2.`'❑ PUMPER YARD <br /> For July 1, f 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 s - ' R.S.or R.C.E. No. - <br /> Te cation Test Date/Time <br /> 4. ).SANITATION PERMITy� #} ` <br /> Job Add-re s/Location <br /> 3!1 � t - --,;` Address <br /> \ZO 1� El PACKAGE PLANT <br /> SerEPTIC TANK ❑ CESSPOOL E)"LEACHING FIELD ❑ SEEPAGE PIT <br /> PERMANENT <br /> 13 TEMPORARY 13NEW ; w,�REPAIR OTHER <br /> l '5.1:❑ CHEMICAL TOILETS For July 1, -June 30, 19 , 1 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(a� <br /> t' :+ 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 �' <br /> } , ) .( Where Certified . <br /> Operator Name ( z (jz <br /> Plant Location v <br /> .Plant Capacity No. Units Servedf' <br /> } <br /> 7. 11 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 /> Home owner orlicellsecta. ent'S igna�tnre erCfPe'srle`o1losnrnr,:`IttT7fyffl.,ilrrtler,:rmanreeitlleworkfarwfiicfilflispermitisissued.I lialinot errployany person <br /> in such manner as to become Suhjast to war' is s cornpensaticr taws�'^a>i1rrl:;a • �- ' f <br /> Contractor's hiring or sI b-c�rit:wL*'snn s: ;s;r:r car'S�e= tt,e i'ctioY�.n9: "! certify tnattlie performance ofthe work for which this per <br /> mit is issued,i shall <br /> employ persons sutiject to watkiran's mirpensaliur,la vs o'.Cali ftjrrdi s ' <br /> 1 hereby certify thaf I have prepared this application and that the work will don in accordance with San Joaquin County <br /> ordinances, state laws, epAiji s and regulati of the San J ji Loci e h Dist 'ct. <br /> APPLICANT'S SIGNATUREX <br /> i <br /> FOR DEPARTMENT USE ONLY I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received B;January 31 ❑ Juty 1 &Received BY July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE ,6HECKED <br /> DATE-- - DATE +REMITTED- AMOUNT <br /> FEE ¢ J e <br /> LESS <br /> PRORATION, ^ • ` <br /> PLUS <br /> PENALTY <br /> `..- OTHER_ ., •° _�,m.x:. •�•r '" '` - 'r <br /> OTHER ..-t•. �y.. ;�^.�.'°c'c�'.r+r�' �� �, r .. � F 3 ,E".�i..F <br /> Received b :'.Date.. «•. F Receipt No. PermiYNtT �.,. lssu nce Da Mailed Delivered <br /> Y . .� +.-# s 4 .. <br /> ,.APPLICANT—RETURN ALL COPIES TO. 'ENVIRONMENT.L HEALTH PEHMIT/SERVICES. - E 1601 E.HAZELTON AVE.,P.O.Box 2009 STOGKTON,CA 95201 <br />