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Applications Will Be Pr messed When Submitted Properly Completed. Be ` To Sign The Application. <br /> �----� APPLICATION2tD <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT w1� 2 — I LP <br /> LIQUID WASTE <br /> Application is hereby made to carry on¢usiness in the jyrisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Z05A Ch1 .eNt2 zLrr, Address_-_21 31 <br /> _ �7, <br /> Owner - 7 _ _Zn -4 �jf1UT'A �fJ <br /> e � 9 753-1 Lo <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No 9 rj 1545 Emergency Telephone No <br /> Contractor Licence No. _ <br /> Applicants Name (Print) Title Date It <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. PERCOLATION TEST <br /> R.S. or R.C.E. Name �"' _ ( tom Z�'� R.S. or R.C.E. No. ZT�-? <br /> Test Location 170 Test Date/Time-t ttr-rxJ Ltz7 �-j �--T-V Art <br /> 4. ❑ SANITATION PERMIT 4 <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 prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. s� <br /> APPLICANT'S SIGNATURE X C J ' Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee I9 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ce�Qteeved by Date <br /> Receipt 4o Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2ELTON AVE.,P.O.So><2002 STOCKTON,CA 95201 <br />