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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> p rr y A (For Non-Transferable, Revocable, and Suspendable) - <br /> ENVIRONMENTAL HEALTH PERMIT gq- 7a-6 AJO. <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA) KiC R+z5�1u2GFiS <br /> Address _d! 2D <br /> a Owner 4 !h_724 Sr'0N_st5 Address 7_3s7y 5'n F£ AD ✓�' IErLI3fITU�- <br /> Firm Partners, Addresses and Telephone Numbers WhN044­1- Q'77/ <br /> aBusiness Telephone No. y`(pL/3`/S Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants Name (Print) &611V D Title iat-16P• 6701-061ST Date AQ-1-90 <br /> Please check Applicable Category (1-7) and Fill in a Required Informal on <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. X PERCOLATION TEST <br /> R.S. or R.C.E. Name /QOti R.S. or R.C.E. No. Z9 � <br /> Test Location P�ti6L / V' 0017fe-4L 2 5ee rn4b'�Test Date/Time WILL 5e4l"C CAC f Psff/W 3/9111--177f f le22-!_ <br /> 4. ❑ SANITATION PERMIT 4 3 Pele-G- 7-7«JTS. SV r*ICE TQt-F Bit-fV e10C�r¢n)r— P6E <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 /> Hornig owner erlicensed egenr'ssignetueeCorti <br /> fies hefollowing:'IceRiffyylha!InthepeAsnmanclQf"workforwhitsthispermitisissueA,lshallnotemployanyp, <br /> in such manner as to income subject to workman'k compensation laws of Califol ria. <br /> Cwntroctor's hiring or subcontracting signoturn cernfins the felkmva g: 'I certify that in Ttw performance of the work for which this permit Is issued.I shall <br /> employ persons subject to workman's compensation laws of California." <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, and ru sand regulati of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 /> BILLING REMITTANCE $ <br /> r/vBFySE EXPLANATION CHECKED <br /> DATEq., DATE REMITTED AMOUNT DUE AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS Z l25Sct. <br /> PENALTY la <br /> O+r� <br /> OTHER <br /> OTHER <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.Box 2009 STOCKTON,CA 95201 <br />