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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 <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Address Phor,,m t_AW5)6aL-A ?14 <br /> a Owner MR R-OBEPM POR9SCA Address 45Zo PnibrT,RYRot 7C^ _94-514 <br /> Firm Partners, Addresses and Telepphone Numbers <br /> a 5JFlEYo1Z"ELECTRO-D15TT ' nG► <br /> a Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 531?53 PtG IvINK'(Ec/T A �5�3Ce PHotJE`(209 Z39-3121 <br /> L Applicants Name (Print) WAL.TESL S. CU MTI n Title e-IYtt_ G:14G 44707 Date (—5--i�A <br /> Please check Applicable Category (1-7) and Fill in the Required Information <'E it 11584- (2o9�3ts?�j' 4ir,9 00MV) <br /> 1. 1:1PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 418 tn-'tid>=w PIALIr �2 ��� S?93 ,!�1r-il <br /> l.nat)cA 9524.0 r>Ar <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 y <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. PERCOLATION TEST Ms S$- 0-1 PAP:EL A 7 <br /> It*=r R.C.E. Name 1P1Ai-T•£9_ 1; CuP'1'tZ5 R!S==R.C.E.No. 11584- <br /> Test <br /> 1Test Location B>i=THKNY SV L-XIA Test Date/Time v i } W4LL,CA4-LWb <br /> oA N'E^9- 'RACY <br /> 4. El SANITATIO�ET <br /> (SEE Pim•PLAi4 OPP'�IUI-M DP <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 l I <br /> Type Construction _ Disposal Site 66a- <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 cv, <br /> (0,0 <br /> Plant Location c <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 /> Homr_owner orllcense4 agent's signrt!ra certifies the following:"I Certifv' -erfo,mancn,of ihnwork forwtrich(This permit is issued.I shall n t e npley any per-,^n <br /> in such manner as to become subinrt in workmar,'S rampensation laws of GafiG r:<, <br /> Contractor's fNring or sub-coni:ar_tinrt signature nercifies the foliowing: ii;Y that m the perform,Ce.ei the work for whichthis permitl: i ced,I r,hail n <br /> employ persons subject to workman s compensation taws of California U <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County P <br /> ordinances, state laws, and rules and <br /> 'regulations of the San Joaquin Local Health District. 0 <br /> APPLICANT'S SIGNATURE X <br /> r <br /> FOR DEPARTMENT USE ONLY D <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING RE ITTANCE $ AMOUNT DUE CHECKED <br /> DATE PATE REMITTED AMOUNT (� <br /> FEE ��. y ©. <br /> LESS v <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />