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Y Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> APPLICATION 9 ' <br /> ( <br /> a (For Non-Transferable, Riiioeable,and Suspendable) s k SEf'TAGE l� <br /> ENVIRONMENTAL HEALTH PERMIT _ <br /> LIQUID WASTE I. A- <br /> Application is hei by made to carry on business 1 the jurisdictional area of t jSan J aquin Local Health District l <br /> HAddress <br /> Business Name (DBA)A �? — --4�' lC"� <br /> z Owner Address <br /> Q , <br /> Firm Partners, Addresses and Telephone Numbers w <br /> CL CL Business Telephone No. ^l^` Emergency Telephone No. <br /> Contractor Licence No. ' .L'1. <br /> L Title Date <br /> L Applicants Name (Print) �. <br /> Please check Applicable Category.(1-7) and Fill in the Required Information- fn <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> -June 30, 19 Disposal Sites <br /> For-July 1, � ' <br /> Description(Make/Yr.,Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity t -�^' Gal:`�Weights & Measures'No- - - �.- <br /> i <br /> Equipment Parking Address t <br /> 2. ❑ PUMPER YARD I <br /> For July 1, June 30, 19 — <br /> ,No. <br /> No. of Vehicles Stored I <br /> No. of Chemical Toilets Stored <br /> 13..�..C1 PERCOLATION TEST <br /> i •-I I 1 R.S. or�.C.E.No. <br /> r R S +or•R:C.E. Name - <br /> ' ` Test Date/Time <br /> ' TO ocatlon t <br /> q,t A ITAT,ION PERMIT <br /> 3Joq 4d¢re s/Location. <br /> ,., u '� Address Z5 ! <br /> fcaner t , . ❑•LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> EPTIC,TANK- , CESSPOOL • ❑ OTHER <br /> .2EFiIVlPa1VENTs � TEMPORARY ❑�NEW REPAIR <br /> 5. C1CHEMICAL TOIL)ETS For July 1, -`J une 30, 19 <br /> t Type Construction <br /> Disposal Site <br /> 4 No. of Units . Equipment Storage/Cleaning Location(s) <br /> LTi."•❑•'PACKAGE{TREATMENT PLANT y' or July 1,-June 30, 19 <br /> Where Certified <br /> Operator Name <br /> I fe l t " ..._17?im.4 <br /> ''Plant toction '�- <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For Julyr 1,-June 30, 19 <br /> SIZE: ElLess Than 1,'000 Sq. Ft.,• ❑ More Than 1,000 Sq. Ft.` - y i ' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Homo ownernriirensed egent'ssfAnettrreCertifies the foilowing:''I cerlifvthafinthe periarmanceof theuwrk for which this permit is issued.I shall not empIq any persoa <br /> in such manner as to become subjdct to wo k r?n a vm�ens�hc ia,rs pt Califor - /, <br /> # Contractor's hiring or:sub-coArac1 noignatur cpr`�arp x," i rat ?v�ir t CCi_:rf!` ':1t in Pm perte;Mm-l'-e(rf the vire c for which this permit is issuedP I shall <br /> employ personj subject to worka,,an'+c i1=.'ve isatl;,::iuLu�„l , t <br /> I hereby certify thatI a ` p epared this application an hat the wor will 4e done in accordance with San Joaquin County <br /> ordinances, state laws n a ns of th Joaqui cal Ith District. <br /> t I <br /> APPLICANT'S SIGNATURE£X t •1 -$Z. <br /> Via.. <br /> FOR DEPARTMENT USE-ONLY <br /> Fee Is Due: ElANNUALLY ElPER UNIT ❑ PER SITE ElEACH ElJanuary 1 &Received B .danuary 31 11 July 1 &Received By July 31 <br /> } .�_y REMIT <br /> E EXPLANATION BILLING REMITTANCE s AMOUNT DUE CHECKED <br /> EBAS <br /> j * -H .. Via..,..DATE - .DATE REMITTED AMOUNT <br /> F � <br /> FEE i l <br /> R. LESS <br /> PRORATION " i <br /> < PLUS <br /> PENALTY r. .a { �: <br /> -y �T'� .� � ��.� r',;_ fid;�� . �,�}� `".,W' .,� «. ..�- .•..;e-. r�.. ....I.: . -,� - <br /> OTHER <br /> M6 Mailed Delivered <br /> Received by Date Receipt NoI Permit No. Issua ce D <br /> ' - 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA'95201 <br /> APPLICANT—RETURN ALL COPIES TO: - <br /> •ENVIRONMENTAL HEALTH PERMITlSERVICES - <br />