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APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendabie) �+(�y T pTAGE <br /> ENVIRONMENTAL HEALTH PERMIT \i �j <br /> LIQUID WASTE (JCA j� <br /> Applicatio/f✓I�{5 hereby made to carry on b si s in the jurisdictional area of the�n J aquin Lop}I HealthDistrict y�q <br /> WT_P ''sae N e BA)-4 _Ar -g Address ° C N <br /> sf`,er Address <br /> Firm Partners, Addresses and Te ones umbers <br /> a Business Telephone No. Emergency Telephone No. <br /> J Contractor Licence No._ A A T <br /> Applicants Name (Print) 'J ro Title �ll`� ! Date <br /> L <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 i, 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. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. <br /> Test Location _ Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location /76 93 E N 7'f R Es C"/7v 12 A/ <br /> Owner OO M u AL .4971/6 LE Address <br /> ® SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT 'J <br /> ❑ PERMANENT ❑ TEMPORARY IO NEW ❑ REPAIR ❑ OTHER <br /> 5. 13 CHEMICAL TOILETS For July 1,-June 30, 19 <br /> 1 Construction Disposal Site <br /> llia,eof 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: <br /> 0,19SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I ) IU /0�3 <br /> 1 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, Mdgesand regulations of a Joaqui ocal Health District. <br /> APPLICANT'S SIGNATURE XCLARENCE'S EPTIC & SEWEP. SERIU4E <br /> E63 So. Oro * Stockton, Calif. 95205 <br /> Ht.d53-32�J �;ontractar's Lic.•;: :i?-� <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT fflp�R SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION DATE <br /> REMITTANCE E AMOUNT DUE CHECKED <br /> GATE DATES REMITTED AMOUNT <br /> FEE <00 �— <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER n <br /> OTHER <br /> eived by Date Receipt No. Permit No. Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2006 STOCKTON,CA 95201 <br />