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APPLICATION' ... ...� �..M, . <br /> ''.. (For Non-Transferable,Revocable,and Suspendable) 1 <br /> .16 <br /> ENVIRONMENTAL HEALTH PERMIT SERTAGE <br /> LIQUID WASTE <br /> 'Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> eusiness Name(DI3A) ��conall Sop Address1�i `� - <br /> Owner T. R. M6 Don Id Address Vallie <br /> Firm Partners, Addresses and Telephone Numbers <br /> i Su'siness Telephone NO. Emergency Telephone No. 9 5 74 X27 <br /> i Contractor Licence No. 13 3 6 7 9r� <br /> ;Applicants Name (Print) Title _91.1114 Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1, 0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> t, <br /> ;., For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> 1: <br /> Serial No. CAL. License No. CAL. License Renewal No._ <br /> t'Capacity <br /> � Gal.,Weights & Measures No. <br /> ' Equipment Parking Address <br /> a$2. ❑ PUMPER YARD <br /> I <br /> rfor July 1, June 30, 19.' <br /> No. of Vehicles Stored <br /> ,No, of Chemical Toilets Stored <br /> 13. ❑ PERCOLATION TEST <br /> R.S.or R.C.E.Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> `f 4. ❑ SANITATION PERMIT!r f - , i--• 3 <br /> *Job Address/Location 1� r.. fr, i,' •,rr' / �f, f .J i <br /> 'Owner �` `" Address _ C» <br /> `V-SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD .b--SEEPAGE PIT ❑ PACKAGE PLANT • EA <br /> 11 PERMANENT ❑ TEMPORARY E) NEW ❑ REPAIR 11 OTHER Q i <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site j <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> S. ,❑ PACKAGE TREATMENT,PLANT For July 1, -June 30, 19 <br /> Operator Name "' r <br /> Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 1 Q <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> 1 i <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 regulatiirs of the San Joaacfin Local Health District. <br /> i J <br /> APPLICANT'S SIGNATURE X `f! Jr,W i ?""�•..r.f ' <br /> FOR DEPARTMENT USE ONLY � <br /> Fee Is Due. 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION <br /> DATE REMITTED AMOUNT DUE CHECKED <br /> ,}�' DA AMOUNT <br /> FEE "t' -- C�"/ f� . <br /> LESS ��Il <br /> PRORATION <br /> PLUS <br /> PENALTY {� <br /> t OTHER g� (/ <br /> OTHER <br /> Received by Date Receipt Ni;. Permit No, I uance pate Mailed belwered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL,HEALTH PERMIT/SERVICES 1601 E.NAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />