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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION 9 i 7 � <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT ID E LV <br /> LIQUID WASTE <br /> Application is hereby made to c rry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA) h&t1tJIPJDG FuazA Address 2� L VI r'J 4� <br /> Owner T'>�P�P�Y P/�L?A 2/—QA.ddress '�2'��(/ ELM ST L.0y I c: <br /> J Firm Partners, Addresses and Telephone Numbers 696a <br /> Q. Business Telephone No. �(Q�'/o�O�71 Emergency Telephone No. 3,6?9 "6o 194— <br /> Contractor <br /> 94— <br /> Contractor Licence No. i <br /> a Applicants Name (Print) S-fEVr '151 FECH)m Title G• E. Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> I. ❑ 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 <br /> 3. SA PERCOLATION TEST � <br /> R.S. ol® S Name TEVZ' �(_,H 1 J R.S. or C. No. <br /> Test Location 1!O 5G ><_ &64W)?4)9,P rA6aE0 Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br /> Type Construction Disposal Site <br /> No of Units Equipment Storage/Cleaning Location(s) PAYMENT <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 REMVED <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served _AN JOAQUIN COUNTY <br /> 7. ❑ PD�LAUNDRY For July 1, -June 30, 19 El hl�l,ri DIVISION <br /> SIZE: Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> L� <br /> I hereby certify that I have pre application and that work w' e done in accordance with San Joaquin County <br /> ordinances, state laws, and r ; dtegLIations of an a In Lo ealth District. <br /> APPLICANT'S SIGNATURE X . <br /> TEST HOLaS - PaCX-_-L. 1 -d- PeRL �'L <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> 42.CV <br /> T l �2 Z�S �L—�-?j '�� J/ . <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Recei Date Receipt t No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />