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APPLICATION <br /> %,.t Nan-Transferable, Revocable, and SuspendabltN,#0 SEPT,.AGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in thea urisdictional area of the an Jo a uin Local Health District <br /> Business Name (DBA)���_PAP_2 ksEl�—sof4s <br /> z Owner Address T <br /> c <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. 4&G—��o7 Emergency Telephone No. <br /> Contractor Licence No. Z <br /> a Applicants Name (Print) 1 M S Title Date tri l <br /> Please check Applicable Category (1-7)and Fili,in the Required Information <br /> L-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. 1 <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> f, <br /> 2. ❑ PUMPER YARD <br /> ; ply 1, June 30, 19 <br /> No. o Vehicles Stored <br /> 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-,L_oc�ation Test Date/Time <br /> `.A. SANITATION PERMIT - <br /> .Job-Address/Location 7 4 <br /> Owner SAttMQS HACA _1t7Af-AV Address _ � z <br /> a'SEPTIC TANK ❑ CESSPOOL BLEACHING FIELD ❑ SEEPAGE PIT `"❑'PACKAGE`PLANT <br /> 13 PERMANENT ❑ TEMPORARY E?nEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 - <br /> ,Type Construction Disposal Sits'` � <br /> t..No. of Units Egulpment Storage/Cleaning Location(s), Z�. - <br /> :6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name ' Where Certified; <br /> Plant Location <br /> Plant Capacity No. Units ServedY <br /> . F <br /> 7. ❑ LAUNDRY For July 1,-June 30, )'5— <br /> SIZE: <br /> 9 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> I--❑ DRY CLEANING, Chemicals Used/Amount/MO. <br /> hereby certify that I have prepared this applicati and t the work will be done in accordance with'San Joaquin County <br /> ordinances, state laws, r I ..and r elation the n oaqu Local Health Disthtrl.- <br /> Sw APPLICANT'S SIGNATURE X <br /> V.; FOR DEPARTMENT USE ONLY t <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 .❑ July 1 �,Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION - 1: AMOf1NT DUE CHECKED <br /> HATE PATE REMITTED -s, AMOUNT <br /> r <br /> FEE <br /> LESS �♦ / <br /> PRORATION r L�" � <br /> 1.r <br /> PLUS <br /> PENALTY <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.HAZ TO AVE. P.O.Box 2009 STOCKTON,CA 95201 <br /> �_� 4114 <br />