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Applications Will Be Pi,Iftwased When Submitted Properly Completed. Be To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMITI <br /> I F'R�- - S`1 1 <br /> 1 ? <br /> LIQUID WASTE . M'S-y <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) Address <br /> OwnerMi(_IAE EL1ZA�1`7 7-Ax Address PELII R_ 95220 <br /> J Firm Partners, Addresses and Telephone Numbers 0209) j.,9""-4-G7 A _ <br /> K Business Telephone No. Emergency Telephone No. _ <br /> J Contractor Licence No. <br /> a Applicants Name (Print) L FZ �L . CUIP-7— Title CIYII_ EN!--zj141=F9 Date 4;;z1:7 <br /> Please check Applicable Category (1-7) and Fill in the Required Information cE# 11564-. <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4-1N1�1 AF\N ' ?A <br /> For July 1, _-June 30, 19 Disposal Sites I�dJDi �f�11-%FERN I^ tel! _ <br /> Description(Make/Yr., Color) :249 3 G ,,—!4 159 <br /> Serial No. CAL. License No. _CAL. License Renewal No._ <br /> Capacity Gal.,Weights & Measures No. _ <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ZPA��E,,r -� <br /> For July 1, June 30. 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored _ <br /> 3. ® PERCOLATION TEST4 ISMq'r*f-1 iFW PU'¢Y"'%) L.OD)1 CA 9_="2_4--c' 3Cu8-'415 <br /> FSC�] R.C.E. Name SAL_�Q � C'�.J kM 1 S R.C.E. No. I l� — <br /> L� <br /> cation 17 P'EL`TlE 12 RGA A U _ Test Date/Time '-jiD Ate( !o I�•- .5 c -c n \_e_o'.� <br /> SANITATION PERMIT Ac^m c. 9� t�'G;i�r }A Inc c�10f1 ff.Ci� e_n 1"�emG `vis) <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/AmounUMo. <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 /> �})T 't� �1J' 734-_ O <br /> APPLICANT'S SIGNATURE X Z�'eL{ lel «��f^ TitleL� � ►'`� ►� Date (6` I CES` <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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT_ <br /> FEE 7L-ar, <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> t•, __ / '� <br /> Received by• 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.Boa 2009 STOCKTON.CA 95201 <br />