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1,1:UC7 Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 2� APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAC,F <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 /> Business Name (DBA) /1/E!L O• /QA&1Cf_504 -P,0WVe_ _TnK. Address 002G -�.@�.4/..iL A"�l �y JQIX 9S�so <br /> i Owner n/6/1- D, 051n /t Can/ Address -'SAe 4£tA41.� DQ. ",0/ 95-2.44, <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. (Zoll) y72—/G"!/ Emergency Telephone No. 33 34'M <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date 1 <br /> Please check Applicable Category(1-7)and Fill In the Required Informatlon <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. 0 PERCOLATION TEST <br /> R.S.or R.C.E. Name_ NE-*L- OA0�� y9 <br /> . 4P4* suw-/ R.S. 00. '1G/ <br /> Test Location SEd MAO 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 /> S. ❑ 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 /> (elpigRplyRfl�arIie{tRap� Rt`i!ItgRs4NtAa_p►tnieRthAfatlawlr,g:"fgariftythalinthepeflornlnnreofthotaorkforwh{chth{spermitisissued,Ishallnotemployanyperson <br /> in syG)t nlafinel as to►)e68 a 811100 of to werkman s compensalinn latus o1 Califwnfa.' <br /> 0111 €9►'# Alritt� ar srlp-e�}ntrsEtinq signature certifies th- tot10"ng; 'I certify that in the performance of the work for which this permit is issued.I Sh311 <br /> )►IS S r;afuJegi to workman's ripmponsalion 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 Coun)y <br /> ordinances,state laws,a es and reg tions of the San Joaquin Local Health District. J 7, ly G - <br /> APPLICANT'S SIGNATURE X �r <br /> e4, <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 0 4.00 L �Ol l p�-Joca 0C <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received y Date receipt No 'ermit 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 />