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I1'/�/11.ew114110 fr 111 ue I IVFeaaeM •r•1111, vwwrl wl.r.v v'rv..� ..1r.�.v... .. �.3.. A ..rr_.-�_.--.. ._ <br /> APPLICATION <br /> Jr Non-Transfer able;°Revocable,and Suspends. . SEpTAGE <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 (DB i,,, 2059 Nav Dr.' Stockton Ca <br /> M E.Rf�L- #v}� - ANG Address <br /> Owner _r1� Q� S�N1C Address_15_A_ <br /> C <br /> U <br /> Firm Partners, Addresses and Telephone Numbers <br /> � J7Z�Bmsr enc Tele: - <br /> a Business.Telephone No - 3 7$ g y phone No._(_2 0 9} 5 2 7-Q94 0 <br /> Contractor Licence No. _ wZQ <br /> � N aFT.RM_ <br /> LApplicants Name (Print) - � Title J? .Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information �+ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> ForJuly'1 , ^„June 30 ,..p, <br /> 19 . <br /> , °__ _ :: 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. Ct P.ERCOLATION TEST " <br /> R.S.or R.C.E. Name - L-INSPECTION ( .5.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT 7 <br /> Job Address/Location t J <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT CL PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY © NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> II <br /> Type Construction Disposal-Site i <br /> No. of Units Equipment Storage/Cleaning Locations)._ <br /> 6. ❑,PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name -- _ Where Certified <br /> Plant Location <br /> i <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 Use <br /> I hereby certify ve prepared this application and that the work will be”it ne in accordance with San-Joaquin County <br /> ordinances, St a laws, a rul s an regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> JE S WRY,' P.. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 0 ANNUALLY ❑ PER UNIT ❑ PER SITE © EACH ❑ January 1 &Received By January 31 ❑ July 1 &'Received By July 31 <br /> BILLING REMITTANCE g REMIT <br /> BASE EXPLANATION DATE PATE REMITTED AMOUNT DUE CHECKED <br /> ___:AMOUNT <br /> FEE <br /> t <br /> FEE ) C `` <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Rede eec by pate Receipt No. Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES' 1601 E_HAZELTON AVE..P.O.Box 2009 STOCKTON.CA 95201 <br />