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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT Z_ <br /> LIQUID WASTE <br /> Application is hereby made to arty on business int the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA)/►�'��` O, <br /> /,149ZA SO 9 4!;S'04, Address !?dZ& 4t+,eA/!'M/4F/>)lic'•�Z/y �I2iG�9y�i <br /> Owner /✓F/L '0.- A/Jp S QI✓ _ Address X06 G£72.aRD ��'Z yZ <br /> Firm Partners, Addresses a d Tele hone Numbers <br /> Business Telephone No. –/C),l Emergency Telephone No. Z01 J U'y -U,74 <br /> Contractor Licence No. _ <br /> Applicants Name (Print) O^,/ Title /o/LFs��G-moi' Date Z <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. 19 PERCOLATION TEST M'e y/R.S. o C.E ame VV4/ R.S. or R.C.E. No. WtJ` t'. /4nG0�'i2s <br /> Test Location 5 4th 72-411`/c0 m,lt Test Date/Time 141i't-4– Nb;/G� <br /> 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 /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19_ <br /> Type Construction _- Disposal Site <br /> Vo of Units Equipment Storage/Cleaning Location(s) — - <br /> i. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Dperator Name <br /> Where Certified <br /> dant Location ---- — -- <br /> 'lant Capacity '•tr' No. Units Served <br /> �. ❑ LAUNDRY For July 1, -June 30, 19 - <br /> >IZE ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> DRY CLEANING, Chemicals Used/AmounUMo. <br /> 161g2 ?4W-JaJlit"I 5A-&" J`.-k aws.k( .D/D d r- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Co my <br /> ordinances, state laws. / <br /> APPLICANT'S SIGNATURE X Title S I t7 Date 4 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION S A <br /> DATE DATE REMITTED MOUNT DUE CHECKED <br /> (=P <br /> AMOUNT <br /> FEE � (�d I_ f�— <br /> LESS ----- <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> aX_—7— - "X <br /> Received by date Receipt No � _erm N-No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Bos 2009 STOCKTON,CA 95201 <br />