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o� <br /> 3� Applications Will Be Proved When Submitted Properly Completed. Be S a Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) `_3- <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 (DBA) -__6ARMA_ 1�. > <br /> � Address �.�, ,_- <br /> Owner___....-�Ar a -__ ... i` Addresses <br /> Firm Partners, Addresses and Telephone Numbers7� � �"' — - <br /> Business Telephone No. __— _ Emergency Telephone No No.-- - - -` - - ---- -Y -- - -- <br /> Contractor Licence No. _ � _� ---- - <br /> Applicants Name (Print) . LCL _ s <br /> �:1yi Title _:> �. ��---- Datote .__�_i <br /> Please check Applicable Category (1-7) and Fill In the Required Information 4-ti3 MA,7TJ4TW <br /> 1. 0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) LOt,I,C 1'3 9 a24-0 <br /> For July 1, June 30, 19 Disposal Sites _--_ x'„—cq_j -- <br /> Description(Make/Yr., Color) - --"- <br /> Serial No. CAL. License Na. <br /> CAL. License Renewal No. <br /> Capacity _ Gat., Weights R Measures Na. _ -�- - -- <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. A PERCOLATION TEST 4-18 MI4,-r7rJZ-YY - <br /> d3a�a�L R.C.E. Name - _... iF� __-- . Mgt- R.C.E. No. <br /> Test LocationLZn ,.A�lp1..�>��� L�7�+i Test Date/Time _ ALL <br /> 4. ❑ SANITATION PERMIT(REYE'R_10 MAP o t.l <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 <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 y $J <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Useount/Mo. /2 --- <br /> _. <br /> 1-,rA445�G�•� '```� f ` to _2 <br /> I o-2 <br /> l hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, stale laws. <br /> APPLICANT'S SIGNATURE X —.!_. - __ —. Title C:NIL-TE�=+tNET r-- Date --- <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER 517E ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 s Received By July 31 <br /> _ .— REMIT <br /> BASE I EXPLANATION BILLING REMITTANCE - $ AMOUNT DUE CHECKED <br /> DATE DATyE REMITTED AMOUNT <br /> FEE <br /> LESS I <br /> PRORATION T-- <br /> us _US <br /> MALTY — -.-._.—_.... _ ....- ---- <br /> �._ ._.Y...— _. <br /> ER <br /> :p <br /> D to Receipt Permil No issuance Date Mailed Delivered <br /> 4WLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON.CA OS20 <br />