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Applications Will B ocessed When Submitted Properly Completed. L, cure To Sign The Application. <br /> APPLICATION _ <br /> (For Non-Transferable, Revocable, and Sus K z �'� 2v"1jlP <br /> ENVIRONMENTAL HEALTH PERMIT le) t-4514" 92_ –I 21 <br /> LIQUID WASTE <br /> F Application is hereby made tp carryon business in the jurisdictional area of the San Joaqquin Local Health District <br /> Business Name (DBA) _1_gtio_`T-w 'L7-1 1 L7 <br /> — �- --L1`L L._. Adtlress_ Se . L4ryyne-vS IZfl <br /> Owner __. � r e,arlr ---- - <br /> S�tz -_�_J taL ' Address 9f> IZxl+aap V, �— <br /> Firm Partners,Addresses and Telephone Numbers - crlw CLSG 1 A� 14PN0 IL7 tI et 4s'i <br /> 1`- EIn2A Iwlc _ Z'St_ M IE,tLE r <br /> LL Business Telephone No. .___.___ <br /> Contractor Licence No. -- - --- — Emergency Telephone No. <br /> Applicants Name (Print) _ EDwAgA7 T t Rey <br /> Please check Applicable Cat (1_7,)and FIH In the I----- ------ Title Ssn� t=uti Date 111 1131_,2 <br /> on <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRAT ON(FOR Eu CHI VEHIR*qnformCLE) <br /> For July 1,__June 3() 19 Disposal Sites <br /> Description(Make/Yr.. Color)- -- -- _- <br /> Serial No. __-- <br /> CAL License No. <br /> ---- --_-------------- — _ <br /> Capacity _ --e ..-----------..-_ CAL.License Renewal No. <br /> --__ 6a1.,Weights 8 Measures No. <br /> Equipment Parking Address --_— _ --- ----- <br /> 2. ❑ PUMPER YARD <br /> For July 1,___ June 30, 19 <br /> No. of Vehicles Stored <br /> 0 of Chemical Toilets Stored <br /> 3. APERCOLATION TEST --- _ <br /> R.S. or R.C.E. Name zuw- H-1mr4 --�1 _ R.S.or R.C.E.No. 'Gq 25S <br /> Test Location =` Ma"' Test Date/Time_TQ $C emenr 1 e3) <br /> 4. ❑ SANITATION PERMIT � -- <br /> Job Address/Location — <br /> -- --- --- <br /> Owner Address_ -- <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 ____. <br /> Type Construction_— Disposal Sitp <br /> No. of Units _ .. Equipment Storage/Cleaning Location(s) <br /> S. ❑ 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. Chari iI�1U7sedF/+`/mfou <br /> A--el9 / /y/M o -- <br /> — <br /> �.>t.{�ef� <br /> >owee�d'0s2 – der.%�'t'fi <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. <br /> APPLICANT'S SIGNATURE X f�_ ._ — Title"TAT F*Ir, . Date I I I 1(j I Z <br /> FOR DEPARTMENT USE ONLY <br /> Fee I9 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Rece.Y By Jarimry 31 ❑Jury 1 l Racafved By July 31 <br /> REMIT <br /> BASE E%PLANATION BILLING REMITTANCE I $ AMOUNT DUE CHECKED <br /> DATE GATE REMITTED _ AMOU T <br /> FEE <br /> LESS <br /> PRORATION -_ _ _- O <br /> PLUS <br /> PENALTY <br /> OTHER ---- -- <br /> ofHER <br /> ---------- <br /> Y ale Ra-c,pi No Permit No IaaUaroi,Dab MaiN I Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA LTON AVE,P.O.eea 2M STOCKTON,CA 95201 <br />