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Applications Will Be Proces When Submitted Properly Completed. Be Sure 1 gn The Application. <br /> APPLICATION p <br /> (For Non-Transferable. Revocable, and Suspendable) 1'�1 -9 "�c�t4 <br /> ENVIRONMENTAL HEALTH PERMIT ICAk-1rzt-'�. ►4.4Z <br /> LIQUID WASTE - <br /> Application Is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,slness Name (DBA) _ Address <br /> vner _JA E� t-1t LEy.KAI LF FRgMJ4_ Address 247 S I Noon A k9N1.ir-r L <br /> rr1 Partners. Addresses and Telephone Numbers (-2�g) <br /> Ismess Telephone No _ _- Emergency Telephone No. <br /> )ntractor Licence No. ___ _ <br /> pllcants Name (Print) Y�LI.-TE� L_`1 l`�_-_ Title C N IL_E14G I WEEC—' Date <br /> ease check Applicable Category (1-7) and Fill In the Required Information TZ•c• r *,I.84- <br /> ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4-1f� MA'TTHSW PLAZA, <br /> ,r July 1,_ _ June 30, 19 Disposal Sites _ �-A • JL4 e-, _ <br /> Iscription(Make/Yr., Color) _. _ _ L 4-1-59 <br /> real No _ _ CAL. License No. CAL. License Renewal No _ <br /> ipacity _ Gal.,Weights 3 Measures No. <br /> luipment Parking Address _ -- <br /> ❑ PUMPER YARD 9 i f�I49 <br /> it July t, June 30, 19 _ _ �WI-EV-5, 1 A <br /> �. of Vehicles Stored <br /> of Chemical Toilets Stored _ <br /> ® PERCOLATION TEST rt-F� s� �r' S_14 <br /> c�� )��R • 159- <br /> S�-ar R.C.E. Name Vy --I F_(Z C_ 9;8:::er R.C.E. No. el <br /> st Location . 7-- i,t4l211-1 Kr-14 F14--#L RChDTest Date/Time �` ,k CALtL _f L_- 3Al2t Sia ARE _i�ALIuG <br /> ❑ SANITATION PERMIT(MORTIA tJ FSAHANT n/\U <br /> b Address/Location r—SES. FC)- <br /> vner __-__ _- Address <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT L <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> ❑ CHEMICAL TOILETS For July 1 - June 30, 19 <br /> ,pe Construction Disposal Site <br /> > 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 `v <br /> ZE ❑ Less Than 1.000 Sq Ft.. ❑ More Than 1,000 Sq. Ft <br /> DRY CLEANING. Chemicals Used/Amount/Mo. <br /> -1C <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state ;aws <br /> r' -41lsg'6.. <br /> ,PPLJCANT'SSIGNATURE X Title _,L0ylL Date 101 �SI�L — <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &Received By January 31 ❑ July t 3 Received By July 31 <br /> --T— REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOOLINT_ <br /> FEE ���aboa -��pq <br /> SL& <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Raton 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.Boli 2M STOCKTON,CA 95201 <br />