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( ,Applications Will Be Processed When Submitted Properly�Co'mpleted. Be Sure To Sign The Application. <br /> APPLICATION -- <br /> ;. •� (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SEPTA <br /> LIQUID WASTE <br /> Y__7 A_� Q <br /> Applicati s hereby rrkade tigcarry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Na a (DBA) Address 1 <br /> QOwner Address_ �g rJtii4 rC t ^ c� L` <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. &a 3 �,/L Emergency Telephone No. <br /> � Contractor Licence No <br /> LApplicants Name (Print) t VT is•x .+ Title Date <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 /> S 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 /> r 3. ❑ PERCOLATION TEST v <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time— <br /> 4: A!� SANITATION PERMITfes <br /> f 7� _ , <br /> Job Add r ss/Locati n tel n �o` 0.r <br /> Owner k Address—p el <br /> SEPTICTANK ❑ CESSPOOL EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY flK.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 /> PNo. Units Served <br /> Plant Capacity <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 /> 1 <br /> I hereby certify that I have re ared this appy a 'on and that the work will be done in accordance with San Joaquin County <br /> t ordinances, state laws, a rul anc(re IaVnstheSan Joaquin ocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> Iell <br /> FOR DEPARTMENT USE ONLY - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 Cl July 1 &Received By July 31 <br /> ` REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> k LESS ' <br /> PRORATION <br /> t PLUS <br /> \\\ PENALTY _ <br /> OTHER - <br /> { <br /> OTHER r <br /> Received by ti u ate Receipt No. rm'ft o- Issuance Date Mailed Delivered <br /> - <br /> APPLICANT—RETURN ALL COPIES TO:y, ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 45 <br />