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Applications Will Be PrL,,_sed When Submitted Properly Completed. Be SL o Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable. Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby madV to carf y on business in the jurisdictional area of the San Joaquin Local /Health District <br /> Business Name (DBA) Dias �-r l V 4�y Address - <br /> iOwner y Address <br /> Firm Partners Addresses nd Tel hone Numbers <br /> 316( Business Telephone No. '3 1 33 Q--lolzl —_ Emergency Telephone No. <br /> j Contractor Licence No. <br /> Applicants Name (Print) 'tZeFr&,T wa o > _ Title .1� aK.�IG�L---— Date <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. Z PERCOLATION TEST <br /> R.S o R.C.E. ame I ( D _f 10 R.S. R.C.E. o. <br /> Test Location t� �,( �SSL fj. jt��. L.,�AI,r A_Test Date-T me 30 n"'jW- 12 ti, til <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 /> 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 6� <br /> SIZE ❑ Less Than 1,000 Sq. Ft ❑ More Than 1,000 Sq Ft <br /> ❑ DRY CLEANING. Chemicals Used/Amount/Mo <br /> I nereby certify that I have prepared this application gind that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws I f <br /> APPLICANT'S SIGNATURE X _ Title _A:At:.l-C�L- _—_______ Date_,t/ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 6 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $� AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE_ - - - ® C)o <br /> LESS --PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - Ij <br /> OTHER-- - - ---1 --— -- - <br /> awed Cy Date Re.eipt No Permit No I-suance Date Mailed Delivered <br /> aDOLI_ RFTURN ALL COPiFS TO ENVIRONMENTAL HEALTH PERMIT�SERVICES 1601E HA2ELTON AVE..P.O.sox 2009 STOCKTOH,CA 95201 <br />