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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.GE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE "�� <br /> Application I ereby made carry on siness in the' ri'sdictional area of J quin Local Heplth Di I �. <br /> y Business Name (DBA) . Address, t�• lJ� l ,�� J <br /> z Owner. Address —TT <br /> 1"Firm Partners, Addresses and Tele o e, Numbers µ a' I <br /> Q, Business Telephone No. � - Emergency Telephone No. y < <br /> Contractor Licence No. <br /> L Applicants Name (Print) _�• Title w - Date <br /> Please check Applicable Category (1-7)and_Fill hin 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. s CAL. License No. CAL. License Renewal No. <br /> Capacity 's _ ..,Gal., Weights & Measures No.- <br /> Equipment <br /> o.Equipment Parking Address— p'• _--- <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored 1 <br /> .No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST:�ky'} <br /> R.S. or R.G.E. Name = R.S. or R.C.E. No. <br /> Test cation _w h` ; `� Test Date/Time 7 <br /> 4. ;'SANITATION PERMIT <br /> Jab Addres ocation 7 O e'" G.e�l �. �rs-!�� <br /> Owner Address Sa�••+'�- <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD PKSEEPAGE PITS ❑.PACKAGE PLANT <br /> ❑ PERMANENT - ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL'TOILETS' For July 1, -June 30, 19 fi <br /> Type Construction Disposal Site I <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 x _, <br /> F r <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.: I1' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> E { 1 . f. <br /> HOMO oti,EGr�r}iced e��� Q�;'s 'sena+.�rce^M1c..,`�fat'rv.:n Icer?ii;=il t! ihs erfa,Marcraft,lewasl fc-r_^'hi�k1<hispernitisissJed;Esha not�mployanype•ser PT <br /> in scCh marl - as Id`a"'"o; ' lv 'sc-tl��`i 3i1�lTSG.IGrE iuv ..al%H},Eo1r;2;, l � '` r�. <br /> Contractor's-=,ic>n0 ar sb-L _.._mac+ n _ nctlr ccisee a.€otlosirfcU. `I certify ti at in the gerferr ante of the work for which this permit is issued;I srizl <br /> einplay persa>>s z2ject to.vurEnlari s Luriil5t fsa.. n,ww�of Gal""€:or !a." i ' <br /> ` 1 hereby certify"that I have ptepared this application and that the work will be done in-accordance with San Joaq 'n Co ty <br /> ordinances,state laws, and rules and re ul tions of an J q in Local Health District. ' r <br /> 'APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY . <br /> 3 ' <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 v <br /> t - DATE __ _. _ DATE REMITTED - f"- - AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ry <br /> PLUS <br /> PENALTY •} - - - <br /> OTHER ` <br /> OTHER <br /> ! = <br /> c- <br /> Received�by ; Date q 'Receipt No: Permit No. ls!suande Date Mailed Delivered x <br /> �'RETURN ALL COPIES-TO:­4 ENVIRONMENTAL HEALTH PERMIT/SERVICES" "- 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />