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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION kS 012-117 <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ` ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE 1` <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local a..aHtealth�ADistric " <br /> H Business Name (DBA)_D_+ -X�_._ �L <br /> i Owner 5AMyC & AgcVLr Address <br /> Address_-:59M6 105 A6wJ1;_ <br /> Firm Partners, Addresses and Telephone Numbers _ <br /> aBusiness Telephone No.(ZD°/ ) 2-1& Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) _ _ Title 49�Jl/A/F�Z Date g7i <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 /> No. of Chemical Toilets Stored I <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. 7. ef <br /> Test Location /na n /�2Jp���` YL J[[ ate/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address / <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD 1:1 SEEPAGE PIT 13 "PACKAGE PLANT Vp <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER �O <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 30. 19_ i <br /> Type Construction Disposal Site - <br /> No. of Units Equipment Storage/Cleaning Locations) - <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 1 have prepared this application an at the w rk will be done in accordance with San Joaquin County <br /> ordinances, state laws. - - <br /> APPLICANT'S SIGNATURE X Title .SUe2 , Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee 6 Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 S Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT_ <br /> FEEz0_6 x Q <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 2- <br /> ReEeivwi by Dal Receipt No Permit N Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 18111 E.HAZELTON AVE..P.O.00.11109 STOCKTON,CA 95101 <br />