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AppliCatiORS Will Be Processed When Submitted Properly Completed. Be Sure o
<br />APPLICATION
<br />(For Non-Transferable, Revocable, and Suspendabie)
<br />ENVIRONMENTAL HEALTH PERMIT
<br />LIQUID WASTE
<br />Address_
<br />cldress
<br />° Firm Partners, Addresses and Telephone Numbers _ _ _P__C_L"
<br /> ___ _ _ _____ ____
<br />4
<br />t. Business Telephone No. _5_1/72-1,71.1.513 __
<br />Emergency Telephone No._ — — —
<br />7.1 i1 111111111 no Contractor Licence No._ __Y 2 — .3 IS cii -
<br />._
<br />. 1 Applicants Name (Print)-_-_-____ _ _ --___._ _ Title _Caa...)__ti_t..r_ __ Date
<br />
<br />, ptease-check Appli
<br />,tabli Category (1-7) and Fill in the Required Information . -, -..
<br />1. 0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br />For July 1,_ _ .June 30, 19 _ __ Disposal Sites _
<br />Description (Maker.. Color)
<br />
<br />4
<br />---
<br />CAL License No. _,-- •
<br />"
<br />R.S. or R.C.E. No.
<br />Test Date/Tirrte
<br />1.1.•••,••••... •
<br />Job Addsci;ettion
<br />er
<br />SEPT-IC TANK 0 CESSPOOC'r--;- tLEACHING FIEL:D _0 SEEPAGE PIT PACKAGE PLANT Owner LtLca_S • ' Address
<br />No of
<br />6. 0 PACKAGE TREATMENT PLANT For3 July. 1, - June 30,19 _..."... _ck, •,,./. '4
<br />Operator Name . _ _-------'7r '•_'• ._--.,__._L__—--___.-___L---------- _ Where Certified _ —
<br />I Plant Location _ _ __
<br />_,—....- ....... _ ,....--‹........---....."
<br />N. 1
<br />SIZE• Ti Less Than 1,000 Sq. Ft.,,, 0 More 1,000
<br />, 0 DRY CLEANING, Chemicals Used/Amount/Mo. •:._._-__ _ --
<br />E r
<br />!
<br />Application isiri,4made to caracr business in the jurisdictional area of the San Joaquin
<br />Local Health Pat
<br />1-Business Name fDBA) _114 6.e.,.._•=nsz_-__
<br />Serial No. —
<br />Capacity Gal., Weights & Measures No. _
<br />Equipment Parking Address _ _
<br />0 PUMPER YARD
<br />IFor July 1, — June 30, 19
<br />No. of Vehicles Stored _
<br />/. No. of Chemical Toilets Stored _
<br />0 PERCOLATION TEST
<br />R.S. or R.C.E. Name
<br />Test ocation —
<br />SANITATION MIT -. *:.••:g' ;
<br />/8 VS S 0 1041 PS ..,,,.
<br />ie PERMANENT 0 TEMPORARY 0 NEW '' ' )4•RE_PAI-R . i 0 OTHER a -•, -
<br />i. 0 CHEMICAL TOILETS For July 1, - J 'une 30;19 '"----Zti. "--'
<br />, ,,
<br />of Units _ ___ _ Equipment-Sforage/Cteaning-1.1 ocatio_. __ - _j_ _ _
<br />. -....,
<br />...'" k i• 1/4•-•"
<br />.•"*. •
<br />. Type Construction Disposal Site
<br />..., , ___ _____ ,. .______Z' ;_____ _ _____ ____ _ _ .
<br />C‘Al._•LiCense-Renewal NO.
<br />-- --?•• - ..---_,.. -__ ,—. . . . . _ .---..., _.-.7. - 1
<br />____:- _ _ — ___--s '
<br />\ s...S
<br />\JIJ
<br />\ Plant Capacity _ _ _
<br />
<br />: •••r Ni
<br />1.••• — t No. Units Served-7
<br /> Than 7, 0 LAUNDRY For July 1,-- June 30, 19 •
<br />1 hereby certify that I have prepared is application and that the work will be done in accordance with San Joaquin County
<br />ations-of tlie,,Sn Joa Lo Health District.
<br />ordinances, state laws, and rules an
<br />SEPT AGE
<br />CAKM41
<br />-;-
<br />Z. Owner
<br />APPLICANT'S SIGNATURE X
<br />5,*
<br />FOR DEPARTMENT USE ONLY
<br />, ... - -
<br />Fee Is Due: 0 ANNUALLY 0 PER UNIT 0 PER SITE 0 EACH . 0 January 1 S Received By January 31
<br />,
<br />REMIT
<br />-
<br />—
<br />EXPLANATION
<br />AMOUNT DUE CHECKED
<br />BILI INCING REMITTANCE $
<br />
<br />DATE DATE REMITTED _-- _ AMOUNT
<br />FEE
<br />—
<br />LESS
<br />PRORATION
<br />PLUS
<br />PENALTY _
<br />OTHER
<br />1 I__
<br />‘/L7 /,/f OTHER
<br />yeci—CY
<br />Permit No. — ssuance Date %laded Delivered —V—
<br />APPLICANT—RETURN ALL comas TO: ENVIRONMENTAL HEALTN PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Sox 2009 STOCKTON, CA 96201
<br />S . ' e •
<br />0 July I & Recelsied By July
<br />BAS F_
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