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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION SCANNED- (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of t San Joaquin ocal Health District <br /> F Business Name (DBA)t?L�PL�91?f,Ska �SI`�A�C• AddressrQ <br /> A Owner Address <br /> 3 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. `���T i _ Emergency Telephone No. <br /> Contractor Licence No.- :—) 5:4+ SLk: <br /> L Applicants Name (Print)���1 [� C( <br /> Y �S_ Tiche I—kkYA%;��. Date i{ -Z 3-S�k 1 <br /> Please check Applicable Category (1-7) and Fill in the Required Information _ A <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 0J <br /> For July 1, June 30, 19 _ - Disposal Sites j <br /> Description(Make/Yr., Color) \.1 <br /> Serial No. CAL. License No. CAL. License Renewal No. f n <br /> Capacity P Y Gal., Weights 8 Measures No. <br /> Equipment Parking Address <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 <br /> R.S. or R.C.E. Name _ R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Addre�sA/Location <br /> Owner ,'t�S L��57_LS Address _ <br /> 11SEPTIC TANK 11CESSPOOL E LEACHING FIELD WSEEPAGE PIT 11 PACKAGE PLANT <br /> 2-1ERMANENT ❑ TEMPORARY 11NEW E REPAIR 11OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 - — <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) " <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> 1 <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. , <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> 1 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, a u}�sand re tions of the n Joa ui ocal ealth District. <br /> APPLICANT'S SIGKIATUREX4LZCG.C. / q <br /> Gj"04 . <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t &Received By January 31 ❑ July 1&Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE cz Q S- <br /> 2-6-LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Fannin No. Issunce 4 Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON ., .O.Soa 2009 STOCKTON,CA%201 <br />