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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) c —� <br /> ENVIRONMENTAL HEALTH PERMIT 5C. TAGS <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District i <br /> OF Business Name (DBA)Ade-A" +g'01,'.CrWAr4ri0,V 44204 Address 141 1 <br /> z Owner Address a <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. _ it Emergency Telephone No. Y <br /> Contractor Licence No. 7 it <br /> L Applicants Name (Print) Title 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 /> 1 <br /> No. of Chemical Toilets Stared <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E.No. <br /> Test Location Test Date/Time <br /> 4. X SANITATION PERMIT <br /> Job Address/Location _ Cg 04, <br /> Owner 4 Address GR*LLA h dV � • <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT \ <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER Q� <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 /> 1 <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 /> hereby certify that I have prepared this application and that the work will be done in"accordance with San Joaquin County <br /> ordinances, state laws, and r les and regula ' ns of the-San Joa n Local Health District. } <br /> APPLICANT'S SIGNATURE X i <br /> 3 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due.-'d ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 ' <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> !LL' DATE DATE REMITTED AMOUNT <br />€ FEE / �1oO ©0 <br /> LESS <br /> PRORATION <br /> i PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> G i <br /> 1-7 s kca- <br /> c'1 c919 9/1 Tsl7ct <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.D.Box 2009 STOCKTON,CA 95201— <br />