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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applfcation <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT 1 PARr�L <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Ith District <br /> y Business Name (DBA) Address <br /> aOwner RE ;" \ _ T Address 4 r O' <br /> J Firm Partners, Addresses and Telephone Numbers CZh9 3��9 4-�Sc� <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants Name (Print) >tVAL_T:F k Title C-Iy+L: lE-- h4 t Wr=MR Date I I—-n'9 <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. PIA�A <br /> 1. C3 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) L8 � 95 4-0 <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 £ A,Lx�P� )C.A• 9Tj`,Z+{5 <br /> �s.o )3�fs-4.159 <br /> R.S. or R.C.E. Name )(yA,t'ZER V . C.URTI� R.S. or R.C.E. No. Ejg4- <br /> Test Location ni I N�RiN —_enwL S P,,nAD - <br /> Ac-AMPn :.� 52 Z� Test Date/Time - - <br /> 4. ❑ SANITATION PERMIT 9 PVkc-c L.A-­LA4 PEAZIN�n`� THVF'=X©Ay Il-'2t` <br /> Job Address/Location _ QM <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. D <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. _ __ '�- k'x,,,0 <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 /> APPLICANT'S SIGNATURE X - Title CI\dlL- #=NG IhiEM rL Date <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 S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS C <br /> PRORATION <br /> PLUS <br /> °ENALTY <br /> THER <br /> HER <br /> 'ed by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> OCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.ae■2009 STOCKTON.CA 95201 <br />