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APPLICATION <br /> ("�r Non-Transferable, Revocable,and Suspenda 5[f'TAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE .. <br /> Application is eby made to carry ot},business in the jurisdictional area of th�San JL9quin Loca�lealt�District <br /> �� Business Name(DBA) i 1�� �./}f,_1 Jti Address r= . ' iaY, &.5 .� , •E j �a'g <br /> F z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> FBusiness Telephone No. —,7Emergency Telephone No. <br /> JContractor Licence No. <br /> L Applicants Name (Print} Title Rale y <br /> FPlease check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) i <br /> For July 1, June 30, 19 Disposal Sites <br /> F <br /> Description(Make/Yr., Color)Serial No. CAL. License No. C-AL:License RenewalNo. v <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 /> j No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E.No,. <br /> Test Location -- Test Date/Time <br /> 4. ❑ SANITATION PERMIT I y <br /> Job Address/Locati -O pec� ��n. 99 l h twjq y ��}����as N '1� ►Tc���1� __ -- -- <br /> Owner A moo Address �• 99 UJJOV 3 J <br /> ❑� SEPTIC TANK 11 CESSPOOL �❑^LEACHING FIELD I®:SEEPAGE PIT X PACKAGE PLANT* Pt PERMANENT C1 TEMPORARY 3r NEW ;KREPAIR 21 OTHER 9V PvzogToIz1 jROAie <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19i�fs?�1ir' �1oiTRt +�/JF� <br /> Type'6ristruction Disposal Site, <br /> No. of Units Equipment Storage/Cleaning Cocation(s�, _ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 `" d <br /> Operator Name Where Certflfied::=_, . <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> FSIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ^ <br /> 1❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Hereby certify that I have prepared this ap <br /> r lication and'that the work will be done irti accordance with San Joaquin County <br /> ordinances, state laws, and es and re ons oft n Joa <br /> F. Local Health District. <br /> APPLICANT'S SIGNATURE X �Q <br /> f I <br /> F 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 /> I REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE `.' DATE REMITTED ,AMOUNT <br /> 0,0 <br /> FEET, i <br /> LESS - GG <br /> PRORATION - - j 7- <br /> /�/ <br /> PLUS <br /> .. PENALTY <br /> OTHER - - T <br /> OTHER _ _ .. - E {•,... - <br /> /aSS �0 <br /> I Received by Date Receipt No Permit No s ce Date Mailed Delivered <br /> " APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:d'tA ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> 4 <br /> I , <br />