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1pp!ic!I nr:• Will 1. Rroci,;seA When Suhmdtl l Propn-ty Completed. E1e SUre To Sign The Application <br /> APPLICATION <br /> (For Non-Tr rnstrable, RtYocablc,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> AppIIC3tlOrrjq her by!n w b Tryon b1e'oneS :r <br /> lunsdichonai area Of the JoaqugvLoeal`Heal'h DI :ct � <br /> P cion k_, Tl- �- ASF •-�/� Addresis ✓ L� 6'.V1 <br /> i Owners (D�AI Address rTlLz!'�� /tC r!•" Qt <br /> 7�5 �� <br /> Firn Partners. Addresses and T leph' Numbers ell <br /> �S <br /> a Business Telephone No 3 �'Q j.S' Emergency Telephone No J <br /> Contractor Licence No. 1 <br /> Applicants Name rpnrn / �C r� � £l£ Title CYexZ'L Gate lC -P--- <br /> Please check Applicaole Category(1-7)and Fill ir,the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) _ <br /> For July 1 June 30. '9 Disposal n•s <br /> Description(Make/Yr Color) <br /> Serial No CAL License No. CAL License Renewal NO <br /> Capacity _ Gal.We,ghts A Measures No <br /> Egwpment FarMing Address _ <br /> 2. ❑ PUMPER YARD <br /> For July 1,--_. __ June?n. 19 <br /> No of Vehicles StoredNo of Chemical Toilets Stored <br /> 3. ❑ PEPCOLATION TEST <br /> R.S.or R.C.E Na— __ _ _ R.S.Or R.C.E.NO <br /> Test Location Test Date!Time - <br /> 4. D'SANITATION F FRMIT <br /> Job Addressatlo T - - ly <br /> �rL n <br /> Owner _/7:�?'C-L- - !..[! Address <br /> ❑ SEPTIC TANK g L:ESSPOCSL 9'CrACHING FIELD a SEEPAGE PIT ❑ PACKAGE PLAN t <br /> ❑ PERMANENT W"fEMPORARY ❑ NEW 0-PEPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 c� <br /> Type Construction Disposal Site - -No.of Units Equipment StorageICleaninq Location(s) - �h <br /> 6. ❑ PACKAGE TREATMENT PLANT For Jt 1. -June 10. 19 <br /> Where Certified <br /> Operator Name -- --- ----—r <br /> Plant Location _ <br /> Plant Capacity --_-- _ No. Units Served - - ---- <br /> 7. ❑ LAUNDRY cor July 1.-June 30, 19 _ <br /> SIZE ❑ Less Than 1.000 Sq. Ft_ ❑ More T.,an 1,000 Sq Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amour /Mo. --------- -- ------ - - ' <br /> Her"nwrw m6ce"WAsAent's$10"ll7 rolcorwie-4IruilMlowfm 1•n•ti•y' •••^'",^r.rgnnJnreO!^•fwnrit,•w' ,^^i.. •• ... -- ^v^"•"."- <br /> msu.;hTanrl.r tc,nbr•Lamasutrert!nwrrkmens .tu�nl,a• •N al` <br /> Contractor's Norm o• sub-eontnrl-n0 n4rllrurc cwAthe^ CM t�tbv..�r !.....! •hat if11'�e�••' r ' 1 <br /> triTsIny persons suujuc?to workman s cpmpeatiatl•n!arts of Cs'tntlPo <br /> I hr}reby certify that I have prepared this 8019icatio and that tiro work will be done in accorda ice with San JoaCu-n GOunty <br /> ordinances,state taws,an and ul o the San Joaquin Local Health District. - - —_ <br /> APPLICANT'S SIGNATIJRE X - f <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ #,ANUALLv ❑PER UNIT ❑ PER SITE ❑EACH ❑ January I R RecewM By Janu I I Cl Ju!y 16 RecenM By July 31 <br /> - -- - -- --� .. .--- -- --- •_ . . REMIT <br /> BASE E%r1LANATION I BILLING I REMITTANCE S AMOUNT DUE CHECKED <br /> i i DATE -- O .E REMITTED _AMOUNT\ \ <br /> d <br /> VEELESS <br /> - <br /> �� <br /> I <br /> PRORATION <br /> y PLUS i <br /> PENALTY -} - <br /> i <br /> OTHER <br /> OTHER _ .. <br /> Dat. Rvcnpt No Pe—d NO I Is once D lie MadPd Doh.- fl <br /> / tT.row.•1 fiv loo/E.HAZELTO 1 AVE..P O ua MOs STOCKTON.CA"NI - <br /> -- APFLICANT-RETUPN AL:COPIES TO ENVIRONMENTAL HEALTH PERMIT.'SERVICE9 1lx 4 ' )L � A, <br />