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tie �ure 1w <br /> "AQplicaiions Will Be Processed When Submitted P.roperlyCornpleteo. <br /> APPLICATION , <br /> (For Non-Transferable;Revocable,and Sus <br /> pendabfe) $EPTAG� <br /> ENVIR0_NMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i reby Tad to car on business i the jurisdictional area of t a oaquin Local Hea h istrict nth bl <br /> Address <br /> rn Business Name (OBA) - Address <br /> .. <br /> aOwner ; <br /> J Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> IL Business Telephone No. 4 ' <br /> a <br /> _j Contractor Licence No. Title i <br /> Applicants Name{Print) <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMiT REGISTRATION (FOR EACH VEHICLE) <br /> June 30, 19 Disposal Sites - <br /> For July 1, _ <br /> Description(Make/Yr., Color) CAL. License No. CAL. License Renewal <br /> Serial No. <br /> Capacity Gal.,Weights &Measures No. t <br /> Equipment Parking Address �_ - — -. •�" # T <br /> 2. ❑ PUMPER YARD { <br /> For July 1, June 30, 19 , '4 <br /> No, of Vehicles Stored s ' <br /> s' <br /> No. of Chemical Toilets Stored <br /> 3," ❑ PERCOLATION TEST _ R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name ) j <br /> f i Test Date/Time <br /> Test Location E } <br /> 4. ❑ SANIITA I ION PERMIT C <br /> i f <br /> Job Addr /Locat'o <br /> i Address <br /> caner LEACHING FIELD ❑ S"EEPAGE PIT ❑ PACKAGE pPLANT <br /> SEPTIC TANK CESSPOOL 1 . OTHER ge# <br /> ❑ TEMPORARY ❑ NEINREPAIR',. �n Laeg `Z4 <br /> PERMANENTW-•+�-s'i 1• <br /> CHEMICAL TOILETS For July 1,'=JuCe 30�, 19 f ! p }JN Sl1rb1P5 r. <br /> ,.AL <br /> �., ..1€_�. __.,j. �•Isposal Site ) # <br /> Type Construction '+ <br /> .,EquipnnentStorage/Cleaning Location(s) 41, <br /> No. of Units <br /> �... <br /> .. <br /> 0, 19 I.,.I-i _F ' fi ( i <br /> 6. 11 PACKAGE TREATMENT,PLANi-T FoiI.*y 1June 3 c Where Certified " <br /> I , <br /> Operator Name f <br /> Plant Location No. Units Served ) <br /> Plant Capacity :;4 W I i <br /> 7, ❑ LAUNDRY For JUly 1, -June 30;19 <br /> ❑ Less Than 1,000 Sq. Ft., C] More Than 1,000 Sq. Ft. <br /> SIZE: <br /> r;E <br /> ❑ RY CLEANIG,CF�emicais Us13d� mo'unUMo- i <br /> rsseownerar �cense aSeA�gs��r�r�r�re �r��Esesth�fotlew:n�€:" cer4r•�'`• tr�' lrr+armarceett,e=gar icru.€c th€spermrtrsissued,4sha,lnntempoyanyPcrs";" <br /> In SllCh manrrei as to become%Aect twrourkCnrli=coltxper! Tien lc^,N'S 6lfiaii_c:1':%= ti� .. [. l <br /> CorftrartoY 5 hsri�9ect to or3cmans.co npeys Doti laws at Ca itorne.gti'9owrng: ."1(CTtity tl�t in ttse pc a:mance of tl;c,wcr4a`or which[itis yer itis issued,l shall <br /> slop of persans s r�; <br /> certify that I have repared this4appl-ication and that< he work will je,doneithDiin accorda�ce with San Joaquin County <br /> 1 11 hereby.{ Y <br /> ordinar(>es',isfate.laws;an les and regu tiols of �arJo u' 'Locatl Health Dstrxl At: <br /> APPLICANT'S SIGN A IJREX." <br /> ; ]�' FOA-DEPARTMENT USE ONLY ) t <br /> 4 y ... _ <br /> ' y REMIT <br /> Fee IS Due: ❑ ANNUALLY ❑ PER?UNIT � PER SITE EACH- ❑4Januarysi &Received By January 31 ❑ Ju(y� Received By July 3 <br /> —'x- REMITTANCE AMOUNT DUF CHECKED <br /> BASE EXPLANATION-T, •N BpATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER j ' <br /> i <br /> et `� ail elivered <br /> Date Receipt Na." <br /> — Permit No. Is u nce la <br /> Received by 1501 E.HAZELTO1 AVE.,P. 2099 STOCKTON,CA 95201 <br /> -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIt/SERVICES <br />