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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ,. APPLICATION , I <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> I �5�PTAE; <br /> LIQUID WASTE ( "[ , <br /> i <br /> Application is hereby made to carry on business in the jurisdictional area o`the San Joaquin-Local Health District, , I <br /> ,n Business Name (DBA) ID -VQARItS14 SONDE .`S1L9C: Address R0 14,�ii S'1"licjl� <br /> i Owner.. Address <br /> Firm Partners, Addresses and Telephone Numbers _ <br /> Q. <br /> Business Telephone No: _9 Emergency Telephone No. <br /> Contractor Licence No. -- <br /> L Applicants Name(Print) g• �IM s 4 �- Title,E--"-"1 *A ©k..Oate !R5- -25 1 —ok <br /> Please check Applicable Category (1-7) and Fill in the Required Information I { r- <br /> -'-�� � � ^. - . : ilk"^ •� - 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) .k <br /> For July t - - June 30, 19:- -Disposal Sites - - <br /> Description(Make/Yr., Color) <br /> Serial No. ( CAL. License No. CAL:.License,Renewal No. <br /> et <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address ' : . - <br /> 2. ❑ PUMPER YARD s 3 <br /> �1x <br /> For July 1, June 30, 19 ' <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored i <br /> 3. ❑ PERCOLATION TEST t <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location`. Test Date/Time Y i <br /> 4. ®KANfTATION PERMIT01 <br /> Job 'Address/Location to <br /> Owner lA-Ad-0 - ;SJ0-4Jl_U41�7w..f Address <br /> ❑� SEPTIC TANK 11CESSPOOL M<EACHI'NG FIELD �EEPAGE PIT ❑ PACKAGE PLANT <br /> Gl-%�RMANENT ❑ TEMPORARY ❑ NEW 9 3-1EPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 t <br /> Type Construction `Disposal Site # <br /> No. of Units x. Equipment,Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July.., -June 30, 19 ! <br /> Operator Name t e Where Certified _ I <br /> Plant Location ' <br /> Plant Capacity No. Units Served ���YT ���� ) <br /> 7. ❑ LAUNDRY,A For July 1, -June 30, 19 1 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING; Chemicals Used/Amount/Mo, <br /> hereby certify thatha�e prepared this applica�iori and`that th'e"wbrK'will be done in accordance with:San Joaquin County <br /> rordinances, state_iaws, ' d ales and reg ions oft an Joaqui ocNHealth IDistrict. <br /> APPLICANT'S SIGNATURE X. <br /> y � S'y; �f ?� c���.•y f"} <br /> __-�--«�*»�FOR-DEPARTMENT USEvONLY.. t $ <br /> w .. � } <br /> Fee IS Dup: 10ANNLIALi1Y.w <❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy t &Received By July 311; <br /> REMIT <br /> BILLING i BILLING REMITTANCE S $ 3 <br /> ! BASE EXPLANATION x AMOUNT DUE CHECKED <br /> --. - - _ DATE - DATE REMITTEE AMOUNT <br /> 8 � <br /> FEE <br /> t': .? ♦ �- <br /> LESS is vJ t <br /> PRORATION 1 p jg E <br /> PLUS 1 <br /> PENALTY <br /> OTHER ! <br /> 3 � 1 <br /> --OTHER <br /> A rte.. 1 A Jf <br /> -. .,. .x„�«.... ... � �' �� w�'V"5....r�'�.J' � �... � •'"...,�....J� .t:-- oi- ..i � .,�1 gF <br /> Received by - Date - 'Receipt No Permit No. Issu ce a Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTO AYE., .O.Boa 2009 STOCKTON,CA 95201 <br />