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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> Al" APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTA G,= <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 /> y Business Name (DBA) 5aaMb [h pta=_n Address 3323 w�im St- Lodi Cc, <br /> i Owner C'IZ Address "7- W Eini L.od 1 Ca <br /> J Firm Partners, Ad resses and Telephone Numbers Q-19-'7- I bilatJMbOd, <br /> a. Business Telephone No. zt'g k(oug Emergency Telephone No. <br /> Contractor Licence No. f� r <br /> Applicants Name (Print) Title �rr rG I Date d- <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 Chemical Toilets Stored <br /> 3. $PERCOLATION TET <br /> R.S. or R.C.E. Name 7L-m K zza R.S. or R.C.E. No. <br /> Test LocationAbm 6wel ts, ��2,87 N, I 3a(YUW&&st Date/Time <br /> J*4. SANITATION PERMIT Road Q&a&" G / <br /> * �"{S, c99- fe6 <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT E�'[ <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER 1P pY 1`�1V i,►,p <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 RE GE <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) in Do <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> 0 <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 /> Homeowmwariicenaadagenes noartilNsMalNbrrifq:-t "in the performance offtwork for which this permit is issued,I shall notemploy any person <br /> In such manner as to beeaafe to word la's compensav")aws of Clwems,. <br /> Cowteacbre I" or "earnwcflne e111fll bafl iea the eeuywine: t Cbrtifythat in 1m pwiurmance of the work for which this per;nd is issued,I shall <br /> employ persons sugect to worlrman's empeftsab"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, a ules and r gulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X -/-- !s t t <br /> (.0Ir <br /> FOR DEPARTMENT USE ONLY r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> IR ceived 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.Boz 2009 STOCKTON,CA 95201 <br />