|
r+� Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. y
<br /> r APPLICATION '-
<br /> (For Non-Transferable, Revocable, and Suspendable) $EPTAGF
<br /> ENVIRONMENTAL HEALT--�4-PERMIT
<br /> 0. LIQUID WASTE �?s
<br /> Applica#ion is hereWby��a e t r o u Ines the ju 's ctiona area of the Sa?Ji quin Loc 1 H al h District
<br /> Or Business Name (DBA)�t-E •Y�i �L � { ddress � P, 6L `
<br /> aOwner ,I Address
<br /> Firm Partners, Addresses anT �shon Num ers
<br /> aBusiness Telephone No. Emergency Telephone No.
<br /> Contractor Licence No
<br /> a �= 'F :r 'CL,
<br /> L
<br /> Applicants Name,,(Print). ��'�+ L ,Title ate
<br /> Please check'Applicable 6ategory�(1-7)and Pill in the Required Information z
<br /> j1 i '❑'PUMPER.VEHICLE PERMITtREGISTRATION FOR EACH VEHICLE)
<br />:--� For July ll June 30,19 • r Disposal Sites
<br /> Description(Make/Yr.,Color) ._
<br /> Serial No. CAL. License No. L- � GAL. License Renewal No.
<br /> !
<br /> -Capacity- �—Gal.-Weights &•Measures-No,----1 -.� �• —_�.�,.. e..,
<br /> Equipment Parking Address I
<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 j
<br /> 4
<br /> R.S.Eor R.C.E. Name � R.S. or R.C.E. No.
<br /> TestLocation iM: Test Date/Time ► '
<br /> 4. ❑ SANITATION P MIT
<br /> 7
<br /> Job'Address/Location—LoillElk ,, f"4r__� 1r P-11IN
<br /> ,O�"ner �-�II� ,�"°""""""w,:`"°"'�'�""_ Address
<br /> "w".....•:•�,,.......�..d, ^�
<br /> y�SEPTIC TANK. 0 CESSP660 LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT
<br /> //❑ PERMANENT ❑ TEMPORARY NEW REPAIR r❑ OTHER '
<br /> CHEMICAL TOILETS ForJuly 1;'=June 30, 19_ _
<br /> Type Construction Disposal Site I
<br /> No.of Units i Equipment Storage/Cleaning Location(s) ! '.
<br /> 'll' ;
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19
<br /> Operator Name p r Where Certified
<br /> .Plant Location
<br /> Plant Capacity IME = No. Units Served i
<br /> 7. © LAUNDRY For July 1, -Ju e,30, 19
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.
<br /> DRY CLEANING, Chemicals UsedhAmount/Mo.
<br /> HC3msowr£'►q;Pseas3s2dag©nf'�C1�:tc«a�a E, s��p3,Q�.c+ -r. �!. sse j�zr, zx ,
<br /> € in u0mai',nera tebece:aes6b� rt -M .4..c t"nW^r f0rwhietrthisgerrnitlsissued,fshallnotem lcyanypersan
<br /> Ccrttccccor s eg w 5tik-£ ta,c a.-t a a 0. ..,e T , l J
<br /> I cr1i:;"! tit file f ;„tancz cf the work.lorwhich this per.lit is issued,I shat!..
<br /> employ persons,ci jCCt tO►'lflfl iur S L'OE7 L.V��.,u.,, 1_ E u ' f '
<br /> N I hereby certify I6ve prepared, applicati and that the work will be done in accordance with San Joaquin County I .
<br /> ordinances, state laws, aI d r nd re lati s f e Sa Joaquin;Local Health District., r
<br /> a 'I � L i � �
<br /> APPLICANT' I _ F �y ;
<br /> FOR DEPARTMENT.USE ONLY #• r i
<br /> i Fee IS Due: ❑ ANNUALLY E] PER UNIT ❑ PER SITE ❑ EACH January 1 &Received By January 31 ❑ July 1 &Received By July 31
<br /> a BILLING REMITTANCE \ { REMIT
<br /> BASE Ef UI LANATION-� ,' $ AMOUNT DUE/ CHECKED
<br /> --- -a -DATE-2 �r�DATE - -REMITTED- '
<br /> `'}� _ .F' v .....,::�,.,...�_ �... AMOUNT
<br /> s FEE-: �i O s/r PL I
<br /> LESS Ip
<br /> PRORATION- iP GYL-
<br /> PLUS
<br /> PENALTY
<br /> OTHER -^ w t`3 ..y, 1.Jf
<br /> AAP #
<br /> OTHER
<br /> Received by Date it Receipt No. Perrril No, Issuance Date filed Delivered ,
<br /> APPLICANT-RETURN ALL COPIES TO: EHYIRONMENTAL HEALTH PERMI7ISERVICE5 1601 E.HAZELTON AVE.,P. , ox 2009 STOCKTON,CA 952♦11� .,
<br />
|