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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL-HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicat�'on,'Is herebypade to carry on business in the jurisdictional area of thl�e San Joaquin Local Health District <br /> Business Name (DBA} jLLO,cJk ,y�;[P' Address •A• D 210 0 57s2¢/ 21$4 <br /> Owner`7j ih 5_ ftcLLCS Address Is >d .Z <br /> Firm Partners, Addresses and Telephone Numbers 3 __„_ _ <br /> L Business Telephone No. 3 Emergency Telephone No, <br /> Contractor Licence No. ” <br /> kAApplicants Name{Print)b4100 K fi/�-�c 01eL Title 4dLJO 5Jo►J01.4 Date 2 3 <br /> - Z~'9 ... <br /> lease 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, 19 Disposal Sites <br /> Description(Make/Yr., Calor) <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 1I- <br /> 2hemical Toilets Stored <br /> 3. PERCOLATION TEST <br /> R.S. Or R_C.E. Na[p@,�F Il ��y R.S.or R.C.E. No. 5Z 7 r'!0 <br /> Tes anon' �f�QD/ G✓�_.._ �3� 3 tai r41F <br /> Test Date/Time , <br /> 4. ❑ SANITATION PERMIT 4 <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER —a <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 � !I <br /> Operator Name Where Certified i <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, 9hernxi als U5 R oun Mo <br /> lee e5o, <br /> 1 hereby certify that I have prepared this application an that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws. <br /> APPLICANT'S SIGNATURE X Title IV450Ar Date <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑July 1 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> q AMOUNT <br /> FEE 3 .`V ^L- Z~ S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 2 2- <br /> ! Receiv Date PeceioMo, Permit No. Issuance Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Bos 20M STOCKTON,CA 9520 <br />