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Applications Will Be Processed When Submitted Properly om <br /> APPLICATION <br /> (For Non-Transierable, Revocable, and Suspendable) <br /> SEPTA <br /> GE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQU10 WASTE <br /> Local Health Dis "ct I <br /> Applicatlol h�ebY ade to carry bu fin s in the jurisdictionaAddressl area of the Sa aq�in �, <br /> ee. ' r . <br /> WF Business Name,(VBA) ! Address <br /> z Owner <br /> Firm Partners, Addresses and Telephone Numbers <br /> Emergency Telephone <br /> . i <br /> CL <br /> Business Telephone No. + <br /> tip t C� f.� Date � <br /> Contractor Licence No. Title <br /> Applicants Name (Print) <br /> ' ' tf <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> June 30, 19 !k. Disposal Sites <br /> For July 1, � <br /> Description(Make/Yr., Color) CAL License No. CAL, Llccnse Renewal No, <br /> Serial No. <br /> Capacity Gat.,Weights &Measures No. <br /> OA <br /> Equipment Parking Address Q. <br /> 2. ❑ PUMPER YARD �II <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time¢ <br /> Test Location , <br /> 4. INSANITATION PERMIT (� J_ }p L_�� <br /> l Job Address/L tion [O /lJ Are/.� <br /> � ���� Address ❑ PACKAGE PLANT <br /> i Owner ® LEACHING FIELD I°' SEEPAGE PIT <br /> ❑ SEPTIC TANK ❑ CESSPOOL J L�REPAIR 11 OTHER <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW <br /> 5. ❑ CHEMICAL TOILETS For July i[ <br /> Type Construction <br /> l-June 30, 19 <br /> k� Disposal Site <br /> No. of Units 'Equipment Storage/Cleaning Location(s) <br /> g. 11 PACKAGE TREATMENT PLANT( For July 1, -June 30, 19 Where Certified <br /> tt <br /> Operator Name <br /> Plant Location No. Units Served <br /> # Plant Capacity <br /> f 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> Than 1,000 Sq. Ft. <br /> SIZE: 13 Less Than 1,000 Sq. Ft., <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have pre d this applica' and hat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r e and re ulation <br /> Joaquin Local Health District. <br /> I APPLICANT'S SIGNATURE X <br /> l <br /> FOR DEPARTMENT USE ONLY <br /> PER SITE El EACH ❑ Sanuary 1 &Received By January 31 © July 1 &Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT REMIT <br /> BILLING REWTTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE Y <br /> 1 LESS <br /> I PRORATION <br /> I PLUS - <br /> PENALTY <br /> 1 <br /> OTHER <br /> OTHER O ALJ <br /> ailed Del vered <br /> Date Receipt No. <br /> Permit Na. 155 ance Date <br /> 1601 E.HAZELTON AVE.,P. :Box 20419.. STOCI(TON,CA 9520 <br /> Received by <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES" <br />