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Applications Will Be i`,essed When Submitted Property Completed. Bey a To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati n s hereby madelo carry on business in the jurisdictional area of the San Joaquin Local Health District J <br /> F AAl1 ! �t'c+C. Address 026 <br /> Business-N}me (DBA) 062-&- O '^� ~---- '~ -- <br /> Owner_�A /L - --- Address <br /> Firm Partners, Addresses and Telephone Numbers -- - - - <br /> 4 <br /> Business Telephone No. Emergency Telephone No. <br /> �1-�--- - - -- _ <br /> Contractor Licence No. <br /> Applicants Name (Print) S� <br /> /V'�iL O Title �E^ 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. ---- <br /> —_ CALLicense No. ____- CAL.License Renewal No.-----_--__----- <br /> -__- . ---� <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_Z - <br /> 3. X PERCOLATION TEST G <br /> R.S.or R.C.E. Name /✓ezL a. /,4W S7,,l -- R.S. o�C ANO. <br /> �' Test Date/Time �✓/�-�► woT//�Y --- <br /> Test Location ,t5G A�1A - <br /> 4. ❑ SANITATION PERMIT - -- <br /> Job Address/Location <br /> Owner -- Address <br /> SEPTIC TANK ❑ CESSPOOL 13 LEACHING FIELD ❑ SEEPAGE PIT 13 PACKAGE PLANT <br /> 13 PERMANENT ❑ TEMPORARY ❑ NEW 13 REPAIR 13 OTHER <br /> S. ❑ 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 - Where Certified - --- -- - - - <br /> Operator Name ----- -- - - -_ <br /> Plant Location _-_ ----- <br /> No. Units Served <br /> Plant Capacity <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/AmounVMo. - S JIG- cae)�r+c � � S• ) S <br /> Ran C. <br /> -�ff� �AL 5 r 5�-i-V C) <br /> I 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. <br /> Title cafe <br /> APPLICANT'S SIGNATURE X .— v <br /> FO EPARTMENT USE ONLY <br /> ❑ January 1 6 Received By January S1 ❑July 1 8 Received By Jury 31 <br /> Fee Is Due: (3 ANNUALLY _❑ PER UNIT ❑ PER SITE ❑ EACH REMIT <br /> � BILLING REMITTANCE s AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE GATE REMITTED AMOUNT <br /> FEE <br /> LESS -------- <br /> PRORATION ------ <br /> PLUS - -----_.. <br /> PENALTY -- - - <br /> OTHER _- _ ----- - - <br /> OTHER --- - - - - <br /> Abli- �P�-_-�_ _ --- ssuance Date Mailed Delivered <br /> Receipt NPermn NO <br /> ece by Date Wi E HAZELTON AVE P.O.SON 1009 STOCKTON,CA aS201 <br /> RtO <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT,SERVICES <br />