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N-S "�2-4 - <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (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 the San Joaquin Local Health District <br /> Business Name (DBA) 214,L K! M1JlL tf Address p•4• �X ZI&) &"VJD r_A. 4SZ4l ' 7-160 <br /> i Owner 3 16&4E S I Address. ---'3 7C IZ.Tr� "8f_C'q' Qr2'Vro <br /> 0 Firm Partners, Addresses and Telephone Numbers Cul <br /> aBusiness Telephone No. 4xo10 774 -6"C-13 Emergency Telephone No. - <br /> a Contractor Licence No. <br /> A Applicants Name (Print) QPVX_ oq,4^)0 yrL _ Title _GJ4Np S a'2y��a'2 Date 9�Z3� L <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FGR 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 /> No. ofQhemical Toilets Stored <br /> 3. -9 PERCOLATION TEST - <br /> R.S.or R.C.E. Name 3'1>6 MU'a rqq R.S.or R.C.E. No. ¢ 277 /N.S, r `77,4$3 -- <br /> Test Location /97kW-5 1W r Hwy. ISO Test Date/Time /4.M, <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <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 /> 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. �f <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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, <br /> APPLICANT'S SIGNATURE X Title �jrJ�L� Date 9'7 3 -Yr- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE D EACH ❑ January 1 &Received By January 31 D July 1 &Received By July 31 <br /> BILLING REMITTANCE S <br /> REMIT <br /> EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> �•,n�r� AMOUNT <br /> FEE /G' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ce ed by to Receipt o Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—IIIETUPI ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 45201 <br />