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APPLICATION(.,..'Non-Transferable, Revocable, and SuspendableSPTAG <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is"eby made to carry ori business in the jurisdictional area of th-9-5an Juin Loca�ealth_District <br /> Business Name (DBA) f �� ��dri�f L UCo• Address t- IIf 1� � �� <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephon, Numbers <br /> aBusiness Telephone No. b ��6 0 Emergency Telephone No. <br /> Contractor Licence No. r <br /> L Applicants Name (Print. - Title � Date ] <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) lyfl <br /> Serial No. CAL. License No. CAL.License Renewal No. I n <br /> Capacity Gal., Weights & Measures No. J <br /> Equipment Parking Address ° <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicies Stored <br /> E No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST { <br /> R.S. or R.C.E. Name R.S.or R:C.E. Nd:, <br /> Test Location -Test Date/Time <br />' 4. ❑ SANITATION PERMIT �j L <br /> Job Address/L cati �� � 7 ly1 to4VtT�G�I'�; <br /> Owner ��I� �t��,J3 dA dress eO��l n, g� i� +14_j_576_r--k�;.�. �-A <br /> r❑�+SEPTIC TANK El CESSPOOL ❑ LEACHING FIELD 0 SEEPAGE PIT PACKAGE PLANT —'A+ <br /> pl PERMANENT ❑ TEMPORARY NEW KREPAIR OTHER 5_VX FZ1X gT0,%J ;RPA/jj <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br />€ Type'6nstruction Disposal Site_- <br />! No. of Units Equipment Storage/Cleaning Location(si <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 a <br /> Operator Name r Where Ceififiedsk_ �- <br /> Plant Location <br /> Plant Capacity t—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 i6,accordance with San Joaquin County <br /> ordinances, state laws, and r es and re ula ons oft n Joa uin Local Health District.. <br /> APPLICANT'S SIGNATURE X <br /> _...._ FOR DEPARTMENTUSEONLY <br /> Fee Is Due: ❑ ANNUALL'Y ❑ PER UNIT ❑ PER SITE - ❑ EACH. ❑.January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING _ REMITTANCE $ ; REMIT <br /> BASE EXPLANATION - AMOUNT.DUE CHECKED <br /> OATS - .-- DATE REMITTED U 'AMOUNT <br /> FEE cj� l� <br /> LESS <br /> PRORATIONPLUS <br /> PENALTY <br /> OTHER T ' <br /> F"a <br /> i OTHER <br /> Received by Date Receipt No. Permit No. I s Ace Date Malted Delivered <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES 7601 ..JFM EL'ON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />