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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) SEPTP,GE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE KS— 88" 7q`- <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> v;Business Name (DBA) Address <br /> a Owner 32)HN 1, OA.CORS Address 2.823 nC-mggiA L"TRFj:r ?; t <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBt75taesz.Telephone No. (4-ts) 54�,7- o-7AR Emergency Telephone No. <br /> Contractor Licence No. C):'It It;_;S4- <br /> _J <br /> L Applicants <br /> S4- <br /> LApplicants Name (Print) WA'.Z"LER-, E CLJ IS Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information 4-1a MATTNEW PLAZA <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) LODt, GA. 957-4oFor July 1, June 30, 19 Disposal Sites t L09 ) 3(e8 - 41E69 <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. X PERCOLATION TEST KOPre" ADDRESS 283415 E• �tYER RDS C�cgt�N CA• <br /> Fzd;�xu R.C.E. Name .VyAL=I:r=_P_ E- CU T►C A Bzft=R.C.E. No. ER4- <br /> Test Location MS- 2%8--7A­ PARGEL AA- A� Test Date/Time <br /> 4. C1 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 onlicensed agent's srg rilf performancf!oftheworkforwhichthispermitisissusd,Ishallnotemployanyperson <br /> In such manner as to become sub,ect <br /> Contractor's hiring or sub-certracting s:c: th r„ow;n 'I : reify +;.:: o;Mance sf the work for which,'.,3 permit is issued,I Shall <br /> emptoy erscns subject to work;na:i; u. <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 regulationsof <br /> - <br /> offthe <br /> -San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ��-�/t� — <br /> FOR DEPARTMENT USE ONLY ✓, <br /> Fee IS Due: 11 ANNUALLY PER UNIT PER SITE EACH ❑ January 1 &Rece' dy anuary 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION R ED AMOUNT DUE CHECKED <br /> DATE DATE <br /> AMOUNT <br /> FEE / <br /> LESS <br /> PRORATION <br /> PLUS / <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receive ate I Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLIC T—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />