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_ i ApFlications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> �� °� �� APPLICATION
<br /> (For Non-Transferable, Revocable, and Suspendable) G�E
<br /> ENVIRONMENTAL HEALTH PERMIT /()—
<br /> LIQUID WASTE
<br /> ApplicatioJn'iis hherebyy ma ee to carry on business in the jurisdictional area of the San Joa
<br /> CLq Di i t 9 s
<br /> ,F Business Name (DBA) � G//V/f1. C.�t, f/��i Address I
<br /> aOwner Addreas ,y,�, r, n
<br /> J Firm Partners, Addresses an ele one uu/rnpb_e ��,,,���//���AA�// _7-, 4 1��w 4CC' ' i /VrI 1
<br /> aBusiness Telephone No. � j�d � � — Emergency Telephone No.
<br /> Contractor Licence No.
<br /> a Applicants Name (Print) �t/9lV �/ U Title 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. }.PERCOLATION TES �'
<br /> R.S. or R.C.E. Name m&h , R.S. or R.C.E. No. SIN,
<br /> Test Location 11,2k& N. /��7 ��. /�+ Test Date/Time Iw� I-SyI • _ 40" to P"
<br /> 4. ❑ SANITATION PERMIT ".P/ 9S2-40
<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
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.
<br /> ❑1MRY CLEANING, Chemicals Used/Amount/Mo. - -
<br /> nNtttutroto►RcAnser�ru+Yltsig,t+rt,+.oc9r.P+.st1►wfo0 I r:..
<br /> 17 SUCK m3rtner aS t.'S1xSUt:'eC't0 wUr'<19T:rA s CO!�.,:f158t'ti f?t••.;' '•L•-,:-,
<br /> t"'i^9 ' cF•_ ttha!°nthe POdermancenftheworkf0rwhichthfsperrnitisiswed.Ishaf:Pot em (olr
<br /> (�nr+traetor's hirigq a 1.. P .arryperson
<br /> emptor;)t r50G8 sirb�eci to worlcmali s�aapensat .; u,,' ,` I,3ariify that in the Pertorrr,ar.'Le a'it.a work for which thls parmii is issued,l;,hall
<br /> I hereby certify that I have prepared this applicatio nd that the work will be done in accordance with San Joaquin County
<br /> ordinances, state laws, and r s and reg do he nJoaquin ocal Health District.
<br /> APPLICANT'S SIGNATURE X�� - - - ---
<br /> ' Gco�e5 aC$
<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 /> REMIT
<br /> BILLING REMITTANCE $
<br /> BASE EXPLANATION AMOUNT DUE CHECKED
<br /> DATE DATE REMITTED
<br /> AMOUNT
<br /> FEE C,0 j24,2
<br /> / 9 S/)
<br /> LESS
<br /> PRORATION
<br /> PLUS
<br /> PENALTY
<br /> OTHER
<br /> OTHER
<br /> -MR q - �S
<br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16011 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201
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