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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 4_1 APPLICATION <br /> (For Non-Transferable;Revocable,,and Suspendable) / gpTAGE <br /> ENVIRONMENTAL HEALTH PERMIT f <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictionsl area of thv Pan J qu Lo I�ealth <br /> tiBusiness Name (D A)jl' Ad ess <br /> z Owner _ Address <br /> j Firm Partners,Qresses and Telephone Numbers <br /> a <br /> Business-Telephone No:. - Emergency Telephone No. <br /> Contractor Licence No. r. v <br /> L Applicants Name (Print) CrIP3VQK� -,Title 4 Date <br /> - <br /> Please check Applicable Category (14)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> t <br /> For July 1,..June 30, 19 --.Disposal Sites. <br /> Description(Make/Yr., Color) <br /> Serit-NO. CAL. License No. J15 CAL. License Renewal No. W <br /> -h L <br /> Capacity Gal.,Weights & Measures No.-A -�-+ - <br /> Equipment Parking Address <br /> 2. ❑.PUMPER YARD <br /> h For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> I No. of Chemical Toilets Stored - <br /> 3. ❑ PERCOLATION TEST ? <br /> R.S. or R.C.E. Name " ,4 kR J or R.C.E.No. <br /> Test ovation _ Test Dat_/Time <br /> 4. SANITATION PERMIT `% %, # -4 • I i".I <br /> Job Address/Location l <br /> Address �lry <br /> Owner - _ <br /> ❑ SEPTIC TANK ❑ CESSPOOL I] LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 'k❑ NEW XREPA R ❑ OTHER <br /> 5. E] CHEMICAL TOILETS For July 1,-J�un.re 30, 19 V00 a►- k C <br /> Type Construction s" <br /> ('^ 'Disposal Site" ..w..._ <br /> No. of Units Equipment Storage/Clem ng,Locatlon(s) MI <br /> is 6. ❑ PACKAGE TREATMENT PLANT For July i, -June 30,'19'1' <br /> Operator Name <br /> Where Certified ( f <br /> Plant Location <br /> Plant Capacity No. Units,.-Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 -- <br /> SIZE: El Less Than 1,000 Sq. Ft.,: 11 More Than l,6 00 <br /> Sq. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> 'Horne ownertxtieensedagent's>3igr>alurece 3flesthaioSte�wtng:"}�EILiTY!tiRtintAE¢B ormartmoftheworkfor which this permitisissued,IShatlnotemployallypersan <br /> fin such manner as to become subject to workmt!P 5 c rr ersatlor�1a s-ryi Ga!iloi II:. • ( <br /> .Contractors hl+iog or sr,h-cnntractinf;- s= l <br /> ignature cwf'fir:s :Tie.-e+t r•i�g: '1 cCl'ity that is ifrelp^rfer:=lanae c!the work for which this permit is issued I shall <br /> employ persons subject to workman's cor;;l;eilsatlon lac s of Gaiiwr:iia_' / <br /> I hereby certify that'l have prepared this application and that the rk Willsb done in accordance with San Joaquin County <br /> ordinances, state laws, and ruleA and regulatio1W of the San Joaquin Local Neaith District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER'UNIT' ❑ PER SITE ❑ EACH ❑1dra�yf 77!&'Recdi ed By January 31 July 1 &Received By July 31 <br /> p <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE- "� <br /> LESS <br /> + PRORATION <br /> PLUS r <br /> PENALTY ) - <br /> t <br /> OTHER <br /> OTHER . . - <br /> Received by 'Date Recclipmd,- Permit No. Issuance Date Mailed Delivered <br /> :� APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />