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<br /> Applications Will Be Processed `7-
<br /> F IF .�
<br /> When Submitted Properly Completed. Be Sure To Slgn The,Application.„ ,, g
<br /> APPLICATION ' Y
<br /> (For Non-Transferable, Revocable,and Suspendable)
<br /> ENVIRONMENTAL HEALTH-PERMIT (m
<br /> I�
<br /> LIQUID WASTE ' € °' ;-. . __1
<br /> Application i',s hereby made to car on business in the jurisdictional area of the San Joaquin Local Health-District.
<br /> F
<br /> Business Name{DBA) RR15�- fQS X�C, Address
<br /> a Owner Address �.
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> CL
<br /> Business Telephone No. -9G,:=)77Emergency Telephone No,
<br /> Contractor Licence No. Z
<br /> Applicants Name (Print) T4L.EMY S. IS(MI& TitleE-S,'rI+ti40' 09'- Date
<br /> Please check Applicable Category(1-7)and Fill in the Required Information
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)a !�-
<br /> For July 1, June 3Q; 19_ - Disposal Sites” "`�� _ - .a 6
<br /> Description(Make/W., Color)' ' r `
<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 a
<br /> R.S. or R.C.E. Name 1 r R.S. or R.C.E. No. 1
<br /> Test Location l Test Date/Time f
<br /> 4. SANITATION PERMIT
<br /> Job Addre%s/Locati n
<br /> Owner 1111-4 Address9�0fg; (-L QO C,$e:e:k f-r_ S Jam)
<br /> E] SEPTIC TANK 1:1 CESSPOOL €9-CEACHING FIELD SEEPAGE PIT. ❑ PACKAGE PLANT
<br /> �lERMANENT ❑ TEMPORARY ❑ NEW 2-TzEPAIR OTHER
<br /> S. ❑ CHEMICAL TOILETS For July 1,-"June 30, 19 'f .
<br /> Type Gonstruction I Disposal Site t +
<br /> No. of Units Equipment Storage/Cleaning Location(s) f f +
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19
<br /> Operator Name Where Certified
<br /> Plant Location a f i ' C! j #
<br /> Plant Capacity '� :-+No. Units Served
<br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ��
<br /> SIZE: El Less Than 1,000 Sq. Ft., More Than 1,000 Sq�Ft.
<br /> ❑ DRY CLEANING, Chemicals Used/Amount Mo. tL,
<br /> l
<br /> I hereby certify that I have prepared this applicatio nd that thew rk will be done in accordance with San Joaquin Coj}�'
<br /> ordinances, state laws, d r lations aSa o uin cal Health District.
<br /> APPLICANT'S SIGNATURE X -
<br /> ( FOR DEPARTMENT USE ONLY 1 t y
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Januar)31 ❑ July 1 &Received By July 31
<br /> # I r - R
<br /> $
<br /> BASE EXPLANATIONV
<br /> rr
<br /> BILLING REMITTANCEAMOUNT DUE CHECKED
<br /> ED
<br /> }
<br /> .DATE..,.,_,•..�,�.,,;.DA7E.,,... REMITTED - .'Y
<br /> er AMOUNT
<br /> FEE �-
<br /> ' /V CS M1 +
<br /> LESS '
<br /> PRORATION r _ d
<br /> PLUS
<br /> PENALTY — — — Sze
<br /> OTHER ,�..-0-,. ^•� w,...� h. .,, ,,,,•• ':. `." '�'}- "�,, �E �3
<br /> OTHER ` _ # ,1•Y e ; "� 4, s �.. ,
<br /> /,z5 s
<br /> Received by _ _ .� Dates Receipt-.No. _ Permit NO. - Iss anc Date Mailed Delivered
<br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201
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