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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT ��`T'�G� <br /> LIQUID WASTE i <br /> Application is hh reby made to car on business in the jurisdictional area of the San Joaquin Local Health District, <br /> O Business Nam (DBA) /`-� �` ��� �L— Address /I �e��FJ6�Z-J> <br /> z Owner. Address <br /> 'a <br /> 'J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. !FE ,55, " Emergency Telephone No. r <br /> Contractor Licence No. Y _ <br /> LApplicants Name (Print) 4 .l i=ce L G-cF: 1� Title .��� Date � <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 t Disposal Sites j <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. Licc:3e Renewal No. E' <br /> Capacity ( Gal., Weights & Measures—No.. — <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD '" 4 , <br /> For July 1, f June 30, 19 <br /> No. of Vehicles Stored ' <br /> a � 3 <br />} No, of Chemical Toilets Sto d� - <br /> 3. ❑ PERCOLATION TEST a,' '' It t <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Addr /Location �, � <br /> 01--- Address <br /> �4 , , -. Address '' XL5� ' <br /> It<SEETIC TANK ❑ CESSPOOL I—LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT �J �� N <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER Q <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction __pisposal-Site_"__� <br /> No. of Units Equipment Storage/Gleaning Location(s) <br /> -11 <br /> 6. 11Ju <br /> PACKAGE TREATMENT PLANT For'July 1, - ne 30;19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity — No.Units 4rved <br /> Af <br /> 7. ❑ LAUNDRY For July 1, <br /> f <br /> SIZE: 11 Less Than 1,000 Sq. Ft., ❑:More Than 1,000 Sq�Ft <br /> ❑ DRY CLEANING, Chemicals Used/AmounVMo. <br /> Q <br /> i 9q�d 3 <br /> _X <br /> I hereby certify that l have prepared this application-and that the w45rk'will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and r4g <br /> Ation�of,the San quln Loca`I Health-ist'rict. " <br /> APPLICANT'S-SIGNATURE X <br /> FOR DEPARTMENT USE-ONLY <br /> Fee is Due. ID ANNUALLY ❑ PER UN! ER SITE "`�❑'EACH ;:❑ January 1 &Rec. d By January 31 ❑ July 1 &ReceiveCi By July 31 <br /> I .. ` REMIT <br /> BASE EXPLANATION - -BILLING REMITTANCE $ +... AMOUNT DUE CHECKED <br /> DATE sDATE REMITTED w- AMOUNT <br /> FEE i C/� C.+I'Yts.. . o j � �,:�-•�,_,�., ., �f7 <br /> LESS .- <br /> PRORATION t�_' <br /> PLUS �. <br /> PENALTY -� <br /> tt <br /> OTHER ' E' <br /> OTHER f --��•-�"^- "'. '' -- .«.""- ! _ _ 3� -- .... <br /> Received by Date iy Receipt No Perm No, ► I suanc Date. = Mailed Delivered . . <br /> . APPLICANT-RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT_/SERVICES 1601 E.HA N AYE.,P.O.-Sex 2009 STOCKTON,CA 95201 <br /> ` <br /> :� , <br />