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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 0 ` APPLICATION 'z_ (>AVzC sL_''5 <br /> n (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 /> yBusinessN�ame (DBA) Address <br /> " L)t'SiN Ai�IL�.WALLYC31M'::�E-7� Address <br /> a Owner <br /> J Firm Partners, Addresses and Telephone Numbers (COCAC ck aCA �* '��=^'�► �' <br /> a Emergency Telephone No. <br /> a Business Telephone No. _ <br /> 1 Contractor Licence No. �+ <br /> 1, trt �vs S Title < Date " e- - - <br /> L Applicants Name (Print)�lA—"L� <br /> Please check Applicable Category;(1-7) and Fill in the Required Information A-IS M A7rrRr=w 1:tAZpt <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Lin r)►, <br /> For July 1, June 30, 19 Disposal Sites <br /> i <br /> Description(Make/Yr., Cokor) � � � <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. of Chemical Toilets Stored <br /> 3. PERCOLATION TEST �'t <br /> Ing,C A 95.2 [ <br /> ��sr.R.C.E. Name �fvf��^t c' Gil G~i1 f R.C.E. No. t=' 1' —Z4r-9cl�cGc�i -� ►- <br /> Test Location •n - ta [atTest Date/Time <br /> 4. c © s <br /> ❑ SANITATION PERMIT (1 �=: G�100 c>r- BQ'I kezt Loc. ';1r3tf MAP A-m-Ae—zi'I*D Tz? f5c_gC `y1�> <br /> Job Address/Location JI �I� '' 'S 1 <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 4-, <br /> S. ❑ 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 /> Where Certified <br /> Operator Name <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. <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. <br /> L Title +I Date z s z_ <br /> FOR DEPARTMENT USE ONLY <br /> t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &ReceiveRdEBy my 31 <br /> BASE EXPLANATION BILLING REMITTANCE Z AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> /-';V 4 a 8 <br /> eceived by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIpONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON.CA 95201 <br />