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x - Applications Will Be Processed When SubAPPd Properly LICATIQNCompleted.Be sure-�ionIgn ,ria^rr=•�� , <br /> y r Non-Transferable,Revocable,and Suspendabk.., SE PTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> h District <br /> Application is hereby made to carry on business in the jurisdictional area ofthe 05 9 Joaquin <br /> Loc17 Dr.al Stockton." Cd. <br /> Address <br /> L Business Name (DBA Address. S NN Chd• '"5 _ <br /> I- �R IR5 N%C W— <br /> aOwner $$ f <br /> J Firm Partners, Addresses and Telephone Numbers �?� q27_ l <br /> Emergency Telephone No. �� <br /> a Business-Telephone No. — <br /> m — _ <br /> _JTON FI <br /> Contractor Licence No. Title Date <br /> Y JESS WRY <br /> LApplicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in,the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For-July 1, June 30, 1,9= - Disposal Sites <br /> 1 <br /> Description(Make/Yr., Color), CAL. License Renewal No. <br /> Serial No. CAL. License 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 -}� _ ��' - �T �.S. <br /> 3. a PERCOLATION TEST or R.C.E. No._ <br /> R.S.or R.C.E. Name Test Date/Time T rJ <br /> Test Location y <br /> 4. ❑ SANITATION PERMIT S / Y S �� � <br /> Job Address/Location <br /> Owner Address <br /> ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT El-PACKAGE PLANT , <br /> ❑ SEPTIC TANK ❑ REPAIR ❑ OTHER <br /> ❑ PERMANENT 11 TEMPORARY ❑ NEW - <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) y� <br /> ti, ❑.PACKAGE TREATMENT PLANT Far July 1, -June 30, 19 Where Certified" - - <br /> Operator Name <br /> r• <br /> Plant Location <br /> ' No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 x <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ` ❑ DRY CLEANING, Chemicals Used/ v _ <br /> k: I hereby certify Ve prepared this application and that the work Will be done in accordance with San Joaquin County <br /> r ordinances, site a laws, a rul s an regulations of the Sang Joaquin Local Health District. <br /> ? APPLICANT'S SIGNATURE X JE S WRY, P P. r• ,-- Tom-- <br /> FOR DEPARTMENT USE ONLY <br /> Fee_Is Due: ❑-ANNUALLY ❑ PER UNIT ❑ PER SITE _ ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveJuly 31 <br /> Rd MI <br /> - BILLING REMITTANCE s $ AMOUNT DUE CHECKED <br /> { BASE. EXPLANATION DATE - -DATE REMITTED— AMOUNT <br /> C <br /> FEE <br /> Sia s3 lc�-��-per [v-tom Fa - " -�n�•�U <br /> LESS <br /> PRORATION - - <br /> ` PLUS <br /> PENALTY " <br /> OTHER <br /> OTHER - ! ,�'• a 7 / / . <br /> Date Receipt o- Permit No. Issuance Date Mailed Delivered <br /> Rec ed by 1501 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES �. <br />