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Applications Will Be I,4all,,:ssed When Submitted Properly Completed. Berme To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <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 /> Business Name (DBA) -.-_ <br /> w Address_ <br /> z Owner <br /> Address 1O �K_7f2N� - <br /> J Firm Partners, Addresses and Telephone Numbers . �- <br /> CL <br /> Business Telephone No. ._ �23�.- 9 L <br /> Contractor+-icence No. — - -- --' - - - Emergency Telephone No. <br /> Applicants Name (Print) <br /> Please check Applicable Cat Title LY1L_�—y pate -. <br /> Category (1-7)and Fill in the Required Information 4-18 ru{ Vy B-PZA, - <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1-0fl1ICALkF<!)RN1A.9524-0 <br /> For July 1, _ _-_ June 30, 19 _-_ - <br /> Disposal Sites <br /> Description(Make/Yr., Color). - <br /> Serial No. - -- - --"CAL. License No. <br /> Capacity � <br /> p y CAL. License Renewal No.- <br /> Gal., Weights & Measures No, No,______ <br /> Equipment Parking Address -- <br /> 2. ❑ PUMPER YARDFor July 1, June 300, 19 <br /> No. of Vehicles Stored _ <br /> No. of Chemical Toilets Stored-4-1.-� t? --"'-~` <br /> - _ *�ll�!1�t Q_1$�r4�,GL�.Lr-.�'.A��2�� _ _.-.___- 'Z• 1r•C_ <br /> 3. ),PERCOLATION TEST (tog) <br /> R.S.or R.C.E. Name1PYAL. {> S- 92-67 <br /> _...-_ �-es R.C.E. No. <br /> Te <br /> st Location P C � Test Date/Time ~ O. <br /> R:�i�l <br /> 4, 11SANITATION PERMIT <br /> 41i! Ccaii�� �ef��4irm1''� <br /> Job Address/Location <br /> caner —. Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL -❑ LEACHING FIELD ❑ SEEPAGE PIT- ❑ PACKAGE PLANT r^ <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW © v <br /> REPAIR © OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction <br /> ---- _.- Disposal Site_ <br /> No. of Units - .- Equipment Storage/Cleaning Location(s) - <br /> 5. 0 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ._-__ _. <br /> Operator Name __. --� . _- - -� .�__... - Where Certified <br /> Plant Location �1 <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. -- - -- - Y <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. OZI <br /> _ <br /> A,cl..Z ""i7/'?z-� r=P3� YL "pv,ti q'i <br /> ordinances,state laws <br /> I hereby certify that I have prepared this application and that the work will-bedoin accordance with San Joaquin County <br /> APPLICANT'S SIGNATURE X Title 5- v Date. •9 - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &Received By January 31 ❑ July 1 6 Received By Jury 31 <br /> BILLING REMITTANCE <br /> $ REMIT <br /> EASE EXPLANATION AMOUNT OUE CHECKED <br /> DATE pAFE REMITTED <br /> - --r-- ---- AMOUNT_ <br /> FEE 2.a(10 a o -� I c _3o�` `f�3 v -TL 2(Z� � 0 f S' <br /> LESS - <br /> PRORATION— — .�— __ .--- •-- �--.....� <br /> PLUS <br /> PENALTY -- <br /> OTHER <br /> } <br /> OTHER <br /> 0 7z- <br /> Received Date --_ Receipt No Permil No �_ Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERINIT/SERVICES 1801 E.HAZELTON AVE.,P.Q.Boa 2004 STOCKTON.CA 4520 <br />