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Applications Will Be Processed When Submitted.Properly Completed. Be Sure To Sign The Application. <br /> APPLICATIQN X ' <br /> (For Non-Transterable,`fievocahle,''nd Suspendable) <br /> 51 P7AGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE.' <br /> Applica ion is hereby ma a to car n usi ess', h juri ,c ion rea of the San Joaquin Local Health.District.. <br /> NBusine s Name (DBA) L— Irlress <br /> a Owner L Address_a5 D . ".KJ Ilt� <br /> J Firm Partners, Addresses and Tele ne N b IS <br /> IL Business Telephone No. `� Emergency Telephone No. <br /> a r <br /> Contractor Licence No. <br /> q r.:.. _ �. /, DC7 <br /> L ApOlicants Name,(Print) - Title t Date - <br /> Please check Applicable-Category(1-7)and Fill in the Required Information -, <br /> a1 ❑ PUMPER VEHICLE_ ,PERMIT-REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June 30, 19 — -Disposal Sites;-- <br /> Description <br /> ites--Description(Make/Yr., Color) Q <br /> Serial No. CAL. License.No J / r = 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. ❑ PERCOLATION TEST <br /> Y x <br /> R.S. or R.C.E. Name R.S. or R.C;E. No. i <br /> Test Location Test Date/Time ) <br /> 4. ❑ SANITATION PERMIT <br /> t <br /> Job Addres 1 o fi n <br /> Owner Addres ' <br /> ❑ SEPTIC TANK! 13CESSPOOL , `-I LEACHING FII=LD SEEPAGE PIT ❑ PACKAGE PLANT f �� <br /> I # REPAIR ❑ OTHt=R <br /> ❑ PERMANENT , ❑ TEMPORARY- NEW '' <br /> 5. ❑ CHEM ICAUTOILETS For July 1, -June 30, 19 <br /> Type Construction, Disposal Site,, <br /> No. of Units Equipment Storage/Cleaning Location(s) s..""� <br /> 6. ❑ PACKAGE TREATMENT PLANT for July 1, -June 30, 19 (/? <br /> Operator Name' �- -• "where Certified <br /> Plant Location' t <br /> Plant Capacity '• No. Units Served ° )_ t <br /> T. ❑ LAUNDRY f For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLE NTNG, Chemicals Used/Amount/Mo. <br /> t <br /> �naturr^_�r5,� r,nr�"irer;itr,4,1 rniheperfar�aaceeftheworkfvrwhiththispermitisi5sued.lShattnaYoiatrY,IR <br /> ftf��err7(�t i to.vor,,7^r <br /> _ ) Y ASS&rJeeTo6}r.. <br /> hat in t33n performance of the work for t7hich 1s3;i perk!.'•IG ilr' �!£'•.' <br /> hereby-eerti# I ha prepared this lication and tti t the work will be done in accordance with San Joaquin County ; cp <br /> orilances, s`�te`.3 an eri a d r ul i n e an a quin al i th District. <br /> APPLICANT'S SIGNATURE X �' ` Q0 1 1 <br /> 00J <br /> Lie <br /> FOR DEPARTMENT USE ONLY <br /> ' Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received 9y July,31�` <br /> BILLING REMITTANCE $ REMIT 4 <br /> .BASE EXPLANATION ;. DATE - -DATE REMITTED- _AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE - <br /> >"' <br /> T .. �.. <br /> LESS } <br /> PRORATION ` <br /> PLUS <br /> PENALTY <br /> OTHER i - -f <br /> r <br /> OTHER .. - <br /> Received by Date Receipt No. - Permit No. Issuance Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />