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Applications Will B ocessed When Submitted Properly Completed. ;ure 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 /> nBusiness Name (DBA) Address_ <br /> i OwnerC. RYAN Atib ELA$Ei{K�?d�=�- Address .1$4�] EIR�T_ COL�I� t"c�Jtt�_CLQ tct`!TS _ <br /> 70 Firm Partners. Addresses and Telephone Numbers _ _ _ "L-IFoRN iA 952-Z-7 � <br /> Business Telephone No Emergency Telephone No. <br /> Contractor Licence No _ <br /> a <br /> Applicants Name (Pant) -KNt-'iER E I' Ajf=�TlS --- Title Date ----- <br /> Please <br /> ate --_--Please check Applicable Category (1-7) and Fill in the Required Information �'� 11--:,84- <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4(�' MA-rrHF-W F ^-R-LA <br /> For July 1, June 30. 19 Disposal Sites Lorzt CA 932 <br /> Description(MakeiYr., Color) 4t S9 <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. 19 PERCOLATION TEST ► 'N '3L�Ai> �� C 2.c'.913(h'-41ty51 8�. <br /> -11 <br /> Firmer R.C.E. Name �y�l _ c'� R.S. or R.C.E. No. tl--,S4 __ <br /> Tes, Location Test Date/Time I <br /> 4. ❑ SANITATION PERMITvE !7 "" <br /> Job Address/Location <br /> i�&C St nE oF'T}11s SNI>:� Fns P^JZC-E-A- MAP <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 �'�P�✓ � �j <br /> ❑ DRY CLEANING.Chemicals Used/Amount/Mo. /L <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 laws. <br /> /J <br /> APPLICANT'S SIGNATURE X hJ (. �! Title CIVIL. EIAGI>~ Date9z <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> - m O AMOUNT <br /> FEE -- — O / Q 1 <br /> LESS (� 1 <br /> PRORATION <br /> PLUS � --- — <br /> PENALTY — <br /> OTHER <br /> OTHER -_--- ----- - — — --- <br /> R eweo by D e Rece-pt No Perrtrtl 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 />