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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) SEPTA;'. \ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatioon is hereby madeto carry Qn business in the ju`isd ctional area of the San Joaquin Local Health District <br /> Business Name (DBA) '1. W . iPQ T I"i L/ t ASS OC l GST i Address Q,4"9 <br /> � V <br /> Owner Lou is e House. Trude,_ Address 402 E . M ar lett Rogd <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. Q 3 :2 62 Emergency Telephone No. <br /> Contractor Licence No. _ <br /> Applicants Name (Print) Stan S / f Q Title AI em t Date — 9� <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 heroical Toilets <br /> Stored 1 <br /> 3. <br /> N TEST <br /> R.S orONameO r1Obet-� G, rIP)U {M R.S. or No. 7, 3,9—) <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <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 /> Homeowner or ricensed egenYs signaturecertifiesthe foffo�virxt:1 certify that in the perfnrmanreof thework for�which this permit is issued,I shall not employ any person <br /> in such manner as to brcome subject to workman's conipensati,on lass•:;falitOrr;i_ <br /> Contractor's hiring or sub-contracting signature uxtflies the "flowing: `i certify L'iat in the performance of the work for which this permit is issued.I shall <br /> employ persons subject to workman's compensation laws of Calitornia.•' <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, nd rules and re IaIt ff Lhh San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X �`��`P�l _ <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANAT BILLING I REMITTANCE $ <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE51 <br /> LESS Q <br /> PRORATION Ur <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date 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 />