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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 /> Applicatio is reby made to carry on business in the urisdictional area of the San Joaquin.Lpcal Health District <br /> r <br /> Business Name (DBA) �"7 h �' F /N,� /�/NAddress '"l /yNT,E� <br /> z Owner 6IJ� Czr 67lL/�A/V Address <br /> a <br /> U Firm Partners, Addresses and jelephong Numbers <br /> aBusiness Telephone No. 2-0 ��� 727 Emergency Telephone No. G O <br /> Contractor Licence No. _ <br /> L Applicants Name (Print) L �N r Cl , 6, /�-dYl�fiv✓ Title Q w 4)071— Date Z <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. K PERCOLATION TUT ll _ / <br /> R.S. or R.C.E. Name ��,y C7j /L�'!/3'N R.S. or R.C.E. No. 3d <br /> Test Locationl r <br /> 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 /> I hereby certify that I have prepared this applicatio and tha he wo 111 be done in accordance with San Joaquin County <br /> ordinances, state laws, and ul s and regulations o he San al Health District. <br /> APPLICANT'S SIGNATURE X <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 <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS , <br /> PENALTY <br /> i OTHER <br /> OTHER <br /> to? _'�algy 9 <br /> eceiv Dat Receipt No. -"Permit No. Issuance Date Mailed Delivered <br /> AP ICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />