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Applications Will Be Proc„"=d When Submitted Properly Completed. Be Su. „-o Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable. Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DIBA)Quali-ty Control In peCtion,—IRC Address 1235_-N_ Rm _raI d Modc s _o <br /> a Owner .S'tP_ye Fredriks —_ Address 22611_ S_. Austin Rd----RipDn <br /> Firm Partners, Addresses and Telephone Numbers (209) 599-$644 _- <br /> i Business Telephone No- Emergency Telephone No.(20912=4940 <br /> Contractor Licence No. _NIA-. Engineering-Testing-Inspection Firm <br /> Applicants Name (Print) Q.C. I . JesaIr Title _P_Fi_x -_EmP214y_ee . Date _1_L19/_9-3._ _ _ <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 19 Disposal Sites <br /> Description(Make/Yr.. Color) <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. 12 PERCOLATION TEST <br /> R.S.or R.C.E. Name Quality Con rol--Inspection R.S. or R.C.E. No. MS-92-154 <br /> Test Location 18977 Austin $d. (See Maps_ Test Date/Time Will Call-_-- <br /> 4. <br /> a] l -_4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <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 <br /> Operator Name ____ _ Where Certified <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,Chemicals U Amo it/ 0 <br /> /!0_/� CO.if� fS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances. state laws <br /> APPLICANTS SIGNATURE X Title PRES/DEN_17 Date V J/ `�_.___ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 3 Received By January 31 ❑ July 1 6 Received By Judy 31 <br /> 9 REMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> — _ DATE DATE I REMITTED AMOUNT <br /> FEE iY /,54-00 ��, r1_-9_9 2- L L + / -00LESS <br /> PRORATION i <br /> i <br /> PLUS -- - ---�--- --- -- --- <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 291by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> APKICAMT—RETURN ALL COPIES TO• ENVIRONMENTAL HEALTH PERWT/SERVICES 1601 E.H"ELTON AVE..P.O.Box 2009 STOCKTON.CA 95201 <br />