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'rr�r s Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applichtion-) •^ 1�
<br /> APPLICATION
<br /> (For Non-Transferable, Revocable,and Suspendable) St PTAGE . ;; r �.
<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 /> y Business Name (DBA) 0 = Address ��• ) 1� . - `S? I
<br /> z Owner Address _
<br /> Firm Partners, Addresses and Telephone Numbers '
<br /> aBusiness Telephone No. —g �7 _ __ Emergency Telephone No. '
<br /> Contractor Licence No.
<br /> �Applicants Name(Print) A?L-�_Y Title Date
<br /> Please check Applicable Category (1-7)and Flll in the Required Information
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) d
<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 TGal.,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
<br /> 3. ❑ PERCOLATION TEST
<br /> R.S. or R.C.E. NameR.S. or R.C.E. No.
<br /> / I
<br /> Test ovation w-Test Date/Time
<br /> 4. SANITATION PERMIT t
<br /> Job Address/Location 3z,� � +D C-A,AA PAC
<br /> Owner jOAP4 1 DEW_ACy—_ Address ISTLoob
<br /> EPT4!C TANK; ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT 1 A4.ERMANENT EITEMPORARY ,,NEWREPAIR C1OTHER5. 11CHEMICAL TOILETS For July 1, -June 30, 19 I
<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,E
<br /> Operator Name Where Certified ��at'.�^^ ✓` r ,
<br /> Plant Location
<br /> Plant Capacity # No. Units Served '
<br /> 7. ❑ LAUNDRY It For July 1, -June 30, 19 ,
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.'Ft:
<br /> ❑ DRY GLEANING', Chemicals Used/Amount/Mo. -
<br /> r._^,{;CC('^'t1,Tnri<;ittilatil?r;lfi;}f',?'ir''li7'"�^�of tillsQemiitS5155UAiI,iShdll liYi 1�1)C+y'3Lly�#°r Ofl
<br /> Home owns.tr>ieensod rad_rY Sig t
<br /> ir1 S Gh'Inan 1eL as iso l�ecam�s�n,f t1G'.'14tH ars cmc I YitvS- I. ? ?
<br /> '.l il; per f 1'.I1.pG O-I {Ja t!;r it i;'•S 7BrfttlY]S
<br /> Contractor' nine� ori
<br /> , � �.� a asre �� � •,_..,,.,,� �.; �__.. LVE'.n
<br /> L:L',INKY:persuRSSE:bi'_'CLI:1'o:'0!:tilia„SCE:�11J�;IEu`:�"'I^�^I� - J.i.,Gil',! ••,••�•^•'•••.•••••".••�- �,-'•
<br /> ' `131 !at
<br /> .I I hereby certify that I have repared this application and that the work illbe done'lin accordance with San Joaquin County
<br /> �! ordinances, state laws, an le and regulatio of the San Jo in L 1-He h Disrict. { - {' 3� Ji
<br /> APPLIANT'S SIGNATURE X
<br /> c
<br /> -.N*,OR_ DEPARTMENT USE ONLY r t
<br /> Fee'IS Due: El ANNUALLY ❑ R UNIT 11 PER SITE t❑N€A,tL El January 1 &Received By January 31 ❑ July 1 &Received By July 31
<br /> - 1 _._.. I Jrf • -HE+ �1 r,r_ REMIT
<br /> ' t
<br /> y BASE EXPLANATION ,8!LUNG r TT4NCE AMOUNT DUE CHECKED
<br /> DATE f DA7F-x• REMITT;[F AMOUNT
<br /> i i � $10
<br /> FEES , . 'r- .,,,•sti
<br /> CIA
<br /> LESS 3 •,� ,
<br /> PRORATION f '
<br /> PLUS ��, '�L"
<br /> PENALTY
<br /> OTHER E __
<br /> OTHER _ _ �^E`ti`•. -""j i t _ 1 � - ....�... � /r r
<br /> Received by -Date Receipt No. Permit No. lissuande Date Mailed Delivered -
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 "�STOCKTON,CA 95201 /
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