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Applications Will Dei ;posed When Subfr1111ed Properly Completed. tae Sure To Sign The Application. <br /> * APPLICATION Q � Pc t <br /> (For Non-Tran lgrable, Rencabla, and $uspendable) c— 1 p <br /> ENVIRONMENTAL HEATH PERMIT N Gt o 1 <br /> 01011,1110 WASTE o`CA l <br /> Appllcatign Is hereby made to carry on business in the juri4digtidn7l area of the San Joaquin Loc§l Health District <br /> 1A Business Name (DDA) DILLCA-) t /�Jurl1"04y _ Addres r0. +2c x 2i�'o !(-D �; ��5241 -Z/5'p <br /> i Owner k-ftil�' Address 'Q Jul 17c) LODt I L�, 4<_Z4-� <br /> JFirm Partners, Addresses and Tel phone Numbers 09 �4- <br /> i Business TelephQn@ N9, �2�'�f 3 34 61 Emerancy Telephone No. <br /> Contractor Licence No. ' <br /> Applicants Name (Print) B eoo 4'6)'Or Titlg� �Np S�K�C' I Date V*"Z9 9L <br /> Please check Applicable Categgry (1-7) and Fill In the RagNlred lnfgrmatiQn t <br /> 1. ❑ PUMPER VEHICLE PERMIT REQ1$TRATION (FOR EACH VEHICI-9) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CA(r. Lit.ens@ No. GAL. Wcpns3e Renewal No. <br /> Capacity Gal., Weights 0 Measures NQ. <br /> Equipment Parking Addres§ — <br /> 2. ❑ PUMPER YARD, <br /> For July 1, ,lune 30, 1y — <br /> No. of Vehicles Stores) <br /> No. of hemical Toilets 5IQred <br /> 3. PERCOLATIQN TEST ZYz <br /> R.S. or R.C.E. Nam@ SIVkp — R.S. or R.C.E. No. *5277 - /t15 — <br /> Test Location 13 e 3lo F c�b� I G— d, - Tg*t P@te/Time 0- 4;1 ?L P 3 O -- <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location - <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL Q LEACHING FIELD ❑ SEEPAGE PIT Q PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY Q NEW Q REPAIR Q OTHER <br /> S. Q CHEMICAL TOIL9T5 For July 1, -June 3Q, 10 <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 Cappwity _ No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: Cl Less Than 1,000 Sq. Ft., Q More Than 1,000 S9. Ft r , <br /> ❑ DRY CLEANING, Chemicals Used/Amoynt/MQ. <br /> A <br /> I hereby certify that I have prepared thio application and that the work Will be done in accgrdonQq with San Joaquin County <br /> ordinances, state law*. <br /> APPLICANT'S SIGNATURE X �// 4;� <br /> ' Pate <br /> Tlt e� t7 <br /> FOR DEPARTMENT VSE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ JOnuary 1 6 Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE i AMOU LIE CHECKED <br /> DATE ATE REMITTED AM LINT <br /> � T <br /> FEE /` (� ' ��'�' -�A <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER / <br /> Received by Date Receipt No Permit No Isauance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRgNM9NTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON Avg..P.O.Boa 2009 STOCKTON,CA 95201 <br />