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Applications Will Be Process When Submitted Properly Completed. Be Sure TNVgn The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) »` L <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 /> iciness Name (06A) _ Address _ <br /> nnert1L�_a-.... ALT_UJ -- -. Address. *-? �- <br /> m Partners, Addresses and Telephone Numbers 4 _- <br /> Isiness Telephone No. — _ Emergency Telephone No. _— <br /> lntractor Licence No. - - <br /> iplicants Name (Print) Title S_.L4� Date <br /> ease check Applicable Category (1-7)and Fill In the Required Information i7Z.L F * i t '84- <br /> PUMPER <br /> ai- <br /> PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) -Ir MF�`THT-W <br /> r July 1, -._. June 30, 19 Disposal Sites t C ", 9 „ _W <br /> -- <br /> rscription(Make/Yr., Color) <br /> rial No. _ _ _ -.- . _ CAL. License No. -__ __ _ CAL. License Renewal No. <br /> Ipacity ___-- _ __. Gal., Weights B Measures No. -----__- <br /> luipment Parking Address <br /> ❑ PUMPER YARD -, <br /> IF July 1, _. June 30, 19 _ <br /> a. of Vehicles Stored <br /> �. of Chemical Toilets Stored <br /> PERCOLATION TEST - <br /> i-�axa <br /> S.'br R.0-E. Name _-_ <br /> R:5:Z5►R.C.E. No. !tom,o,�5-- <br /> -st Location .---.--- - ..- <br /> _t]= _4`? � HAMt-AwF L<�Rl r}3 - - <br /> � ._...�.-_ Test Date/Time <br /> ❑ SANITATION PERMIT ti/�T�1 LhAI /?.�IrJ mal Rr?# T� 'C)1,ltw In- <br /> b Address/Location s R a F _ r A P) <br /> inner -_ Address <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT © TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> rpe Construction _ Disposal Site <br /> 1 of Units _ _- _- _ Equipment Storage/Cleaning Location(s) <br /> ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19_ <br /> )erator Name __._. _-_ . _ ._ _�___-� Where Certified <br /> ant Location <br /> ant Capacity No. Units Served <br /> ❑ LAUNDRY For July 1, -June 30, 19 <br /> ZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> SGC <br /> c?;, 541 os., P'--tc- 7rs:�s <br /> I hereby Certify that i have prepared this application and that the work will be done in accordance with San Joaquin Countyl115`16-`iz <br /> ordinances, state laws. <br /> d I'l T��r r t1 t l�' { 9C <br /> ,PPLICANT'S SIGNATURE X _. .. !.��.-� .-__—_ Title Date W - <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY [3 PER UNIT _❑ PER SITE ❑ EACH _❑ January 1 A Recewed By January 31 ❑ July 1 b Received.By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> — — - - - _ AMOUNT— <br /> LESS 1C� <br /> PRORATION <br /> PLUS <br /> PENALTY Ep <br /> OTHER <br /> ___ <br /> 0T <br /> OTHER <br /> 4r 2 <br /> Receive&fy Date Receipt No Permst No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAIELTON AVE.,P.O.Sox 2009 STOCKTON,CA 9520 <br />