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Applications Will Be F ssed When Submitted Properly Completed. Be To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby ade to carry n business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) _a��l-� MtJ�cl�/ � _ j_ Address l�0- 'k ugh MoD i,C 9SZQ� "yl$CCT <br /> Owner_. ----- — - Address — <br /> J Firm Partners, Addresses nd Te ephone Numbers 4—66 ) <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. tt,, <br /> a Applicants Name (Print) _ oR+ TitleCD 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 Disposal Sites - --- <br /> Description(Make/Yr., Color) ---- <br /> Serial No. _ CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights& Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> Noof hemical Toilets Stored <br /> 3. PERCOLATION TEST r <br /> R.S.or R.C.E. Name JofMV�p __ R.S. or R.C.E. No. 7 M 9L 'OLz <br /> Test Location 10811 "4C'# K&-P0 0-106ca, *,*A Test Date/Time rZ4'9 :vv ��, c:AST 1441'c Abot___ <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location — <br /> Owner — ___ _ _ Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19--- <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 Capacity _ _ No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft <br /> ❑ DRY CLEANING, Chemicals Used/Amount,Mo <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun!y <br /> ordinances, state laws. /,2 fAPPLICANT'S SIGNATURE X A41,1111 TitleL^+Tlry Z��`�� �! Date! <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 d Received By January 31 ❑ July t&Received By July 31 <br /> --�_ REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE _ — --- —-- - O- <br /> LESS <br /> PRORATION <br /> PLUS — --� — -- - -- ------ ----- <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ys� - <br /> R ceived by ate Receipt No Permit No Issuance Date Mailed veered <br /> APPLICANT--RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 25201 <br />