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Applications Will Be Processed When Submitted Properly Completed. Be SureTo sign IneAppucanvn } <br /> APPLICATION ' <br /> Q r, (For Non-Transferable, Revocable;and Suspendabte) SEP TAGE <br /> C;"'1� I '7 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> usin the�j sdictional area oft J quip Local Health <br /> r� <br /> AI � n is Y�ere�b m to arty . - - <br /> rBusin ame (DB Address - <br /> z Ow r Address _ '.' ; <br /> a <br /> J Firm Partners, Addresses and Telephone Nu , <br /> aBusiness Telephone No., Emergency Telephone No. ; <br /> Contractor Licence No. 2-Z Date <br /> T� ~� `^ <br /> 4 Title r <br /> Applieants:Name'(Print} sk ^ � <br /> Please check Applicable C e ry(1-7)and Fill in equired Information r: �L <br /> 46 <br /> ''❑ PUMPER'VEHICLE,,PERMf°T REGISTRATION (FOR EACH VEHICLE) r <br /> For July�i,� . Jude 30;19 DispoSaF Sites ; <br /> Description(Make/Yr:-•Co[or} j� <br /> .Y�y CAL. License No. CAL. License Renewal No. � , <br /> Serial No. Y <br /> Capacity )` + ' Gal.,Weights &Measures No. <br /> Equipment Parking Address 4. <br /> 2. ❑ PUMPER YARD t <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored s <br /> No. of Chemical Toilets Stored t <br /> 3. ❑ PERCOLATION TEST l b ¢ <br /> fR.S. or R.C.E. No. <br /> R.S.or R.0 E:Name <br /> ;Test Location _ Test Date/Time <br /> A. ❑ SANITATj0N PERMIT <br /> Job Add /Loc ti <br /> ,OwDer i f i Address �. <br /> ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑,�,�P `CKAGE PLANT <br /> EPT:IC K L�lJ4'4FI�i-- <br /> EFtMANENl' ❑ TEMPORARY ❑ NEWEPAIR <br /> 5. ❑-CHEMICAL TOILETS For;my 1,-June 30, 19 <br /> Type Construction ;. Disposal Site 1 <br /> No. of Uriits ��- Equipment Storage/Cleaning Location(s) <br /> 6• ❑ pAt!I TREATMENT PLANT For July 1,-June 30, 19 <br /> § %._ -73 r Where Certified <br /> Operator' ame - <br /> Plant LoGat+ori ( # <br /> Plant C&p�It� r No. Units Served I <br /> v -. <br /> _ {, <br /> 7. ❑ eAUNDRY For July 1;.u.�June-30r•19­ <br /> r <br /> 'L ❑ Mare Than 1,000 Sq. Ft. <br /> SIZE: ;gyp s Than 1,000 Sq! Ft., <br /> -w. <br /> ❑ DRY CLEANING-,.Chemicals Used/Amount/Mo. , <br /> II owner osfice 9erlcertifilsthe inflnwing:"I certify thafinThe performanceofth2warkforwhichthispemItisissued,tshaRryotemployanyperson <br /> in suth manrlaFsAo became st[bjeci tfi wi)kmatfs�nmgensaiiorl laws of California." I <br /> Contractor's Wiirig c+r sub-cotracting 'J9?M1t6re certMOS the fL+llOWi0g: '1 c(-;rti`y tt; '1-14he yeriorManct:of the work for which this permit.is Issued,I shall <br /> em.0p 0;Gerson subjLr..LII icTw4:;a cm��zrlsaiirli laws utCali;0:iHa. , r <br /> I hereby certify that 11 In ve prepared this application and that the work will be done in accordance with 5an'Joaquin County <br /> ordinances;state laws, a �ules an .r ation f the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> `� <br /> FOR DEPARTMENT USE ONLY ^� <br /> Fee Is Due: ❑�AN)SUALLY © PER UNIT ❑ PER SITE ❑ EACH January 1 &Received By January 31 ❑ J iy 1 &Received EMIBy TuIy 31 <br /> BASE i EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> f - DATE DATE REMITTED i AMOU <br /> NIC <br /> FEE <br /> LESS i <br /> PRORATION rf ' <br /> PLUS - <br /> PENALTY <br /> OTHER - - s -'t <br /> - <br /> w /7 14 <br /> Is uance ate Mai4ed De4ivered <br /> Received by Date Receipt Na: - Permit No. - <br /> 1601 E.HA7ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> � <br />