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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Appli tion. m- <br /> ;:�'�* APPLICATION ?3- / z- <br /> ' (For Non-Transferable, Revocable,And Suspendable) <br /> u ENVIRONMENTAL HEALTH-PERMIT SPTf1GE <br /> LIQUID WASTE Tic k kp�. <br /> Application is hereby made to carryon business in the jurisdictional area of.the an Joaquin cal Health District <br /> �a I ➢, <br /> Business Name (DBA) �N Gco� � �.�f Addre ✓Z �COT� L`fl�nlT�`G <br /> a Owner ��/i f Address Ito Yj �/sS�!% �] <br /> Firm'Partners, Addresses an Telephone Numbers <br /> G. <br /> Business Telephone No.�xf. }y- - Emergency Telephone No. �� <br /> ;�y F <br /> Contractor Licence No. r ' <br /> -C 5-1 s: <br /> L Applicants Name (Print) � f 7`/f . - Tltie /Z Date:. �` 0 <br /> Please check Applicable Category,(1-7)..and Fill in the Required Information <br /> 1, 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR-EACW VEHICLE) <br /> For July 1, . ----- June 30, 19.__. _. .--.�.:,� �.-- -wDisposal_Sites: <br /> 1 <br /> Description(Make/Yr., Color) ~ <br /> Serial No. }CAL. License No. CAL. License Renewal No. - r <br /> Capacity - Gal., Weights'&Measures Na. ti H _ <br /> Equipment Parking Address <br /> ;2. ❑ PUMPER YARD " <br /> ) <br /> For July 1, June 30, 19 - <br /> No. <br /> 9 No. of Vehicles Stored, ' dd <br /> No. of Chemical Toilets Stored 4 <br /> 3. ❑ PERCOLATION TEST.-- <br /> R.S. <br /> EST R.S. or R.C.E. Name R.S. or R-CkE. No. t <br /> 'Tet Location t Test Date/ Time <br /> 4. SANITATION PERMIT -: } x <br /> Job Address/Location 4 133 ked e-Oi Xq rea 4- ' r <br /> Owner `' �/s Address <br /> SEPTIC TANK CESSPOOL IaLEACHING FIELD 11 SEEPAGE PIT-'"`❑.PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY .-a NEW ❑ REPAIR ❑ OTHER ' <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30,19 P <br /> Type Construction Disposal Site <br /> No. of Units ` 1 Equipment Storage/Cleaning Locations) <br /> .6. ❑ PACKAGE TREATMENT PLANT For July 1;-June 30, 19 (� <br /> .Operator Name i... _ r _ Where Certified__ ,I <br /> Plant Location I # <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19- <br /> SIZE: <br /> 9 SIZE: ❑ Less Than 1,000 Sq1 Ft., ❑ More Than 1,000 Sq. Ft. ' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo <br /> F. <br /> I herebycertify that I have <br /> y pr par d this application an +that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ru s nd reg ations the an Joaq>11n oca ea r+6 t <br /> APPLICANT'S SIGNATURE X <br /> DEPARTMENT USE ONLY t <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE '❑ EACH © January 1 &Received By.January 31' ;[] July 1 8 Received By July 31• <br /> I BILLING REMITTANCE $ REMIT -p <br /> ,BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE_. z DATE. ., ,REMITTED, AMOUNT <br /> i <br /> FEE -; - 8 -- a t <br /> LESS 1 <br /> •-- PRORATION -------------- <br /> - - - - <br /> s <br /> PLUS i } <br /> -PENALTY <br /> OTHER <br /> OTHER ,. <br /> Received by Date Reces t No. Permit No. Issuance D Mailed Delivered <br /> g APP4ICANT—RETURN'ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL TO4-AVE-,P.O.Box 2009 STOCKTON,CA 95201 <br />