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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> sT (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEP7AGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA) 'P.A. AA P-R.1S .5F 50AIS Address pd AeK 14 9_0 S'TC&Tbs✓ 5 i 'e ' <br /> i Owner Address ` <br /> 4 <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. f444 Emergency Telephone No. <br /> Contractor Licence No. a2S'�3SL3 - <br /> L Applicants Name (Print) F-4-"'D + DoA Title Date 7 R <br /> Please check Applicable Category (1-7) and Fill in 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. 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 /> y <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. A SANITATION PERMIT <br /> Job Address/Location '95-41 �LE p.� S-rc�ic-7'a�J 9 soya <br /> Owner L I u p LA VA ifAIIA1,9 Addresreed�I E T <br /> ❑ SEPTIC TANK (] CESSPOOL X §aACHING FIELD 'SEEPAGE PIT ❑ PACKAGE PLANT <br /> IV PERMANENT 1i TEMPORARY ElNEW (REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> r No. of Units Equipment Storage/CleaningLocation(s) <br /> l 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 1- <br /> Operator Name V Where Certified <br /> Plant Location <br /> Plant Capacity No, Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> f SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> l -w <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of th Paquin Local Health District. <br /> APPLICANT'S SIGNATU X ' e <br /> i <br /> low n <br /> ` FOR DEPARTMENT-USE ONLY <br /> i' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE -❑ EACH ❑ 31ary 1 8&Received By-January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> r AMOUNT <br /> qq / <br /> FEE <br /> LESS <br /> PRORATION a ' <br /> PLUS <br /> Ir PENALTY <br /> E OTHER <br /> k OTHER <br /> M <br /> Received by Date- Receipt No. Permit No. Is uance ate Mailed 'Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL'HEALTH PERMIT/SERVICES - 1601 E.HAZELTON A.VE'.,P.O:Box 2009 STOCKTON,CA 95201 <br />