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l <br /> APPLICATION <br /> ` - ( :Jon-Transferable, Revocable, and Suspendablei..,� , <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is ereby made to carryon business in the juri dictional area of the San Joa uin Local Healt�h{D��'5trio <br /> ',RBusiness Name ( A) - c-a .�e o L Address /"P g 76 7 / •—el <br /> Owner '�''+p-1Z' <br /> =irm Partners, Addresses and Telephone Numbers <br /> .3usiness Telephone No. 31'_R SS/ C --T' Emergency Telephone No. <br /> Contractor Licence No. Z 2- 4 <br /> 4pplicants Name (Print) n.,14 . 67� Title <br /> V Date 6 - 6 - 90 <br /> 3lease check Applicable Category (1-7)and Fill in the Required Information <br /> n. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, June 30,19 Disposal Sites 16, <br /> Description(Make/Yr., Color) -- - <br /> ..aerial No. _ CAL. License No. CAL. Liccnse Renewal No. <br /> Capacity ---- - - -- Gal;;-Weights-&-Measures <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 TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. - <br /> Test LXation - M Test Date/Time (` <br /> r,4. (11 SANITATION PERMIT <br /> Job Address/L cation V! <br /> V! <br /> Owner � _ 0� "�� � Address <br /> y <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD 1�9'�S PAGE PIT ❑ PACKAGE PLANT <br /> '❑ PERMANENT ❑ TEMPORARY Q NEW .__ LKREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For JJIy 1,-JU a 30, 19 z' <br /> Type Construction ` t4"` " _ Disposal Site _ _ A <br /> rNo. of Units - -- Equipment Storage/Cleaning Location(s) _ — <br /> r <br /> 6. ❑ PACKAGE TREAT.M'ENf OtANT- For July 1,-June 30, 19 <br /> Operator Name I t' 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/Anlount/Mo. <br /> Q . <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordant h San Joaquin County <br /> ordinances,state laws, and rules a regulations of the Jo uin Local Health District. —� <br /> APPLICANT'S SIGNATURE X - <br /> l• FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑PER UNIT ❑ PER SITE ❑ EACH ❑ januaY)A,January) a ived By January 31 ❑ July 1 &Received By July 31 <br /> BILLING RE TT E REMIT <br /> BASE- EXPLANATION DATE ATE REMITTED AMOUNT DUE CHECKED <br /> 6. AMOUNT <br /> FEE S <br /> LESS <br /> ` PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> LOTHER <br /> A O v <br /> ` Received by Date Receipt No, Permit No. Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,P.O.Box 2009 STOCKTON,CA 95201 <br />