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APPLICATION FOR WELLIPUNIP PERMIT BAN JOAQUIN COUATY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION F P 0 BOX 385,449 N.SAN JOAQUIN ST,STOCKTON,CA 96201.316 (201)"S.342O N111HIUM-ARIF PI?RMT MMES 1 PIAN FNN_OIITt ISIMI! thyMta k TriElleatil A ATION IS NM MY MAGE TO THE MAN JOAOIIIN COUNTY RM A 1Eh,VT TO CONI T1UCS ANOATR NerA THE WORK OMPNED.TNIM AFFucATgN 16 LIAM IN OoNouLA?=RRFN aAN JOAQUIN COUNTY OLVELOPhttNT 6.3 AMI TWE arANOAADE OF MAN JOAQUIN COLRRY PUAUC WALT It ME WICEM,"MMUM UNTAL WEALTH OIVIVON. �.r J06 ADOIEniNn AMN Clrr PA10El nQF/ILTM 71 OMMEIrf _ a ^PHONE � 1 I CONTIV1CTaR AOOA[MM LILLM: n/ PIgILr�- .i 1M�faH1RA4TOR Apply 11C/ PIIOflE1 ❑HTrYWFU d FepS Emmy w6L0 YONrIDNNOIN[lLE 1❑�CTHpI _ �MTAl1ATY1N O svMTFM REPM ❑CROGe ONIECr eEPAJR Q VAPOR'Un"LCTION VALI J �I '^ 1 HA. pEPfN WMPM Pr. FMf WATER LEVEL` O 1 T. Application Wig Be Processed When Submitted Properly Completed.Be Sure To Sign The Applleation APPLICATIONV (For Non-TraMlerabio,'NivYoabie,and Buspenda131e) ? t ENVIRONMENTAL HEALTH PERMIT /�1S "'`Jy- 5� '147 LIQUID WASTE Application is arab made to ca ty 9,n_business in the jurisdictional area of the S�n,4.0 n Local Health Distric n'Business Na�!a�(�D�B��A�� _ �•1` � JE� C.� Ad ress ESC / 7y I owners l�L�'rX�J4 JL/TClVJ^+�? _ Address fiGil,/� LCS S2 Firm Partners.Addresses and Telephone Numbers, _ y r ZLZA_ _ 9,400r, sBusiness Telephone No..-.. Emergency Telephone No. Contractor Licence No. Applicants Name(Printl ..-_ ft —Title 514 Date Please check Applicable Category(1-7)and Fill In the Required Information 1- ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) + For July 1,__-_June 30,i9 Disposal Slles _. Description(IldskeNr.,Color)—_.-_._ t Serial No. CAL.License No. CAL.Uoense Renewal No. Capacity Gal..Weights Measures No. Equipment Parking Address 2. ❑ PUMPER YARD ---- "^ �— II ,For July 1,_._. June So,19 , I No.of Vehicles Stored III No,o1 Chemical Toilets Stored 3. ❑ PERCOLATION TES ` f n c R.S.or R.C.E.Name f1) 1N. S _ R.S.or R.C.E.No. - Tttat Location Test Data/Time 4. ❑ SANITATION PERMIT o��} Job Adaress/Location Owner _ Address ❑ SEPTIC TANK ❑ CESSPOOL 0 LEACHING FIELD ❑ SEEPAGE PIT 13 PACKAGE PLANT V, ❑ PERMANENT ❑ TEMPORARY ❑ NEW 0 REPAIR 13 OTHER 5- ❑ CHEMICAL TOILETS For July 1,-June 30,is Type Construction _. ---Disposal Site - Nc.of Units -Equipment StoragelCteaning Locations) B. ❑ PACKAGE TREATMENT PLANT For July 1,-Jane 30,19 - Operator Name -_._. _ Where Certified Plant Location ------ Plant Capacity No,Units Served T. ❑ LAUNDRY For July 1,-June 30,19 SIZE: ❑ Less Than 1,000 Sq.Ft., 13 More Than 1,000 Sq.Fl. ❑DRY CLEANING.Chemicals Used/Amount/MO. 4 A oo b I hereby Certify that I have prepared this ap a et;on end that the work will be do accordance with San County ordinances,stat,laws. c��,qtr :APPLICANTS SIGNATURE X G _T..-7iileli -C�Data WR DEPARTMENT USE ONLY Fee]a Due:Cl ANNUALLY Q PER UNIT ❑PER SITE Q EACH ❑Jami"16 RECfl Md By January$1 17 Any 1 a MCMIVED By July 31 REMIT BILLING REMITTANCE S BASE EXPLANATIONNDATE DATE REMITTED A�UIrT DUE CHECKED ��r• AMOUNT ` FEE LES, PAORAIION —_- PLUS PENALTY _ OTHER OTHER — lgscN"d 6y D•!e A—P.Na Pwmn No Ipuenco tMp mmiled 0EIir0nd APPLICANT—RETURN LL CORES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 11011.NAZRLTON AYE,M-O.am Stan aTOCKTON,CA miN I I_�