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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ! APPLICATION * 9G 974 -i POI LL IP5 <br /> 1 — (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTACF <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> .usiness Name (DBA) P>AUKAD&CN --k- F/oZZA Address 323 W PEL.t.,/I ST LOBI tip 5152 11 <br /> c Owner -rE-F`%F.-Y P/OZ Address 323 W. ELM sr LDDI . 982.40 <br /> j Firm Partners, Addresses and Telephone Numbers <br /> : Business Telephone No. Emergency Telephone No. ' O <br /> Contractor Licence No. 1 <br /> Applicants Name (Print) 'T>=RRY P/L,7—'ZA Title G•�- Date 2 � 2a— -tom <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. CZ PERCOLATION TEST <br /> R.S. or R.C.E. Name TERnL <br /> FZY p ,Zz A R.S. o C.E. No. Iq(0 J 4j� <br /> Test Location ' 0 qE- JA"A1sLT PxV AGQTest Date/Time_- <br /> 4. ❑ SANITATION PERMIT <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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - <br /> I hereby certify that I have pr this application and that th work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r regulations oft n Jo in Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> -i CST — d GEI <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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �OGI� ✓Wt� p�� 1i—G aL—� .0� V <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Rec by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />