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APPLICATION <br /> (For Non-Transferabte,Revocable, and Suspendable) <br /> • SFF'i. <br /> ^ 1 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl cat n �heerreby m carry <br /> de to car O us ne s I`�the us Clonal area of the Sa-i <br /> _H aith District <br /> Bus- ss Name cDBAl 4a6sil �Cs. -- �� IJOCn2 Address �.S_O f�oaqur^ cal1` <br /> 1U•v �V e <br /> O� Address _ S� t.--_ O <br /> 1 <br /> Firm Partners Addresses and T@f{{�t7faZne Numbers <br /> Business Telephone No. v^_.` 6 5 ' �� Emergency Telephone No CT <br /> Contractor Licence NO. 'a 8 <br /> Applicants Name 1Pnn11 10" CIA—M6r'Le - Title - --- -_. Dale <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 Disposal Sites _ -- -- - <br /> Description(Maks/Yr.,Color) - - _.--- -- — --- -- ____ <br /> Serial No__ CAL. License No. _ -__ CAL.LfL:.se Renowal NO. __.____ <br /> Capacity . Gal., Weights&Measures No - --- -- -- -- — <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD <br /> For July t,. June 30. 19 <br /> No, of Vehicles Stored - - -- - - - - -- - - -- - <br /> No. of Chemical Toilets Stores - - - - <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E Name R.S or R.C.E. No <br /> Test Location - __. -- - Test Date:1 Ione - -- <br /> J SANITATION PERM}T� r n, ,S <br /> Joh Addie anon_ ._ � /�KJ N /'�_ 0. <br /> Owner �. L4j R bH _ Address__ <br /> war <br /> ❑ SEPTIC TANK ❑ CESSPOOL_ ■ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PFRMANENT ❑ TEMPORARY ❑ NEW ■ RFPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS --or July 1, -JUrte 30.Ili— <br /> Ty ':onstruchon _ Disposal Slle <br /> N inits _ -- -_ Equipment Storage/Cleaning Location(s) <br /> 5. U PACKAGE TREATMENT PLANT For July 1, - June 30, 19 _ ••1 <br /> Operator Name --_ __- Where Certified ---- <br /> Plani L cat,on -- -- <br /> Plant Capacity No Units Served _ - -- - - <br /> 7. ❑ LAUNDRY For July 1. - June 30, 19 _ <br /> SIZE ❑ Less Than 1,000 Sq Ft ❑ More Ther) 1,000 Sq. Ft <br /> ❑ DRY CLEANING, Cnemlcals Used+Amount,'Mo. - - - ------ <br /> I hereby certlly that I nave prepared talis aPplicalioA and that we work wil, be done in accordance with San Joaquin Counly <br /> ordinances,state laws. a ,les andRregul ns of a San JUaqu n Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY 0 PER UNl ❑ Pf.R s l l F ❑ EACH L7 January 1 I<Received By January 31 ❑ July 1&Received By July 31 <br /> BILLING REMITTANCE S - REMIT <br /> BASE - I t7IPLANAt10N DATE DATE REMITTED AMOUNT CHECKED <br /> AMOUNT <br /> FEE 7Y - CIS _ <br /> LESS <br /> PRORATION - <br /> PLUS - -- <br /> PENALTY <br /> OTHER <br /> OTHER _ <br /> JY) 31 VTs c <br /> Reeenmed by I Data f -- - -Ileceird No Permit No usnc.Date Ma,iea Delnrared <br /> APPLICANT-RETURN ALL COPin TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E HAZELTON AVE..PO 9oz 2009 STOCKTON,CA 9511011 <br />