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,. Applications Will Be Processed When Submitted Proper y a vv <br /> �• _ , � APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendabte) SEPTA E <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 /> Address l� <br /> mBusiness Name (DBA) Address <br /> l a Owner �°- <br /> 3 Firm Partners, Addresses ana Telephone Numbers Emergency Telephone No. <br /> ILBusiness Telephone No. <br /> Contractor Licence No. Date <br /> Title <br /> Applicants Name (Print) <br /> S <br /> Please check Applicable Category (1-7) d Fill in the Required Information <br /> k 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C7 <br /> ` For July 1, June 30, 19 Disposal Sites <br /> ! Description(Make/Yr., Color) CAL. Licse Renewal No. <br /> Serial No. CAL. License No. '� <br /> Gal.,Weights & Measures No. <br /> Capacity <br /> Equipment Parking Address / <br /> 2. ❑ PUMPER YARD ` <br /> I For July 1, June 30, 19 <br /> ` No. of Vehicles Stored <br /> j No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name ' <br /> Test Date/Time <br /> Test Location <br /> f 4. ❑ SANITATION PE WaT I <br /> Job Address/Location • W <br /> f Address a� <br /> Owner I <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ OTHER P NT <br /> I ❑ PERMANENT 1:1 TEMPORARY <br /> ❑ NEW ❑ REPAIR <br /> 5. <br /> ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site <br /> Type Construction <br /> - - <br /> Equipment Storage/Cleaning Locati s) <br /> No. of Units <br /> �a <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name - <br /> Plant Location No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> 1 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> i ❑ DRY CLEANING, Chemicals Used/Amount/Mo. U15 ``�r <br /> certify that I have prepared this application and that th ork will be done in accordance with Sa Joaquin County <br /> I hereby <br /> ordinances, state laws, and rules and regulations of the San Jo cal He�ltri istrict. r <br /> APPLICANT'S SIGNATURE X, <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t &Received By January 31 ❑ July t &.Receiv REMIT <br /> d By uIy 31' <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> r ,:y <br /> I . �o �a- , ( o 43X� �- f d r s te- <br /> terReceipt No. Permit No. Issua ce Date Maile Delivered <br /> Received by - Date - A6p1 E.HAZELTON AVE.,P.O.Bo STOCKTON,CA 95201 <br /> APPLICANT�RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITI5ERYICE6 <br />