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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 /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F <br /> Business Name (DBA) Address <br /> iOwner Y(0/5 RR$ARA DcaCx�N Address 130<n FAS7T Z:t%,JIAt,rr I?c�A��t�1Fb C'A 9St2�? <br /> u Firm Partners. Addresses and Telephone Numbers ZZ�y) 333-7182 <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants Name (Print) WAL'"PER c r_u F�7ri-N Title c;04iL E.WG►ilNEE t, Date Au l•,T -jT9j9 s <br /> Please check Applicable Category (1-7) and Fill in the Required Information C ,Is8dr <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 418 PLAZA <br /> - 4-Q <br /> For July 1, June 30, 19 Disposal Sites 9 5 <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. ;ff PERCOLATION TEST 418 MA-T-rNrw PLAZlA;`fib+,GA 9�2q-O C1)3�8-4'+S9 <br /> R.C.E. Name wI,--1 E K E Gu RTl S R*sr-R.C.E. No. I IBRA— <br /> Test Location IMILE E <br /> is o D O Test Date/Time��J°W_ k"9—91 k'gAl�n.►GS 8��• ci <br /> 4. 11 SANITA I tI PERMIT' ''51p7' 'nF JAA14k"r90AD�AC)SrAF0 CA TAtAA+4T k'oAD / <br /> 5R� 3nAcly t ccs, W <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 C 1 <br /> Type Construction Disposal Site <br /> No of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19y <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 /> Horne owner or licensed agent's signaturesnrtinasthefouowiricertifythatintheperiormanceoftheworkforwhichthispermitisissued,Ishallnotemployanyperson 7D <br /> in such manner as to become subject to workmali s compensation laws of CalifurrliaL, <br /> Contractor's hiring or sub-contrr sting signntvre certifies the foNuw.ng: `I ceriiiy that in the performance of the work for which this permit is issue(! <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, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> _c/r ' Pr7 !f"r~c(� O/9 / �� �45T�ra li��� $ <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 /> REMIT v <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> DIM <br /> AMOUNT DUE CHECKED <br /> FEE -•• , ;J 'i'✓ / / tf:� L�/�,7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ecei d by Joate 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 />