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Applications Will Be Prosed When Submitted Properly Completed. Be SG-..00 o Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable <br /> ENVIRONMENTAL HEALTH PERMIT ms's L� <br /> LIQUID WASTE lz <br /> App€icattq�j; ere�y made to c rry on business i the jurisd11 ional area Of the San Joaquin Local Health District <br /> Business Name {DBA) - _ 4 !Q" �tfS�f/S ,w�ss��: _ Address k( <br /> a Owner . II - — - — `i <br /> +!_ _.l. Q. /-- !n_ -�..+� SA✓� Address <br /> Firm Partners, Addresses and Telephone Numbers -1 ----- - - <br /> - - --- -- <br /> aBusiness Telephone No. ,2�9_ 7 q ------ - - - ----- <br /> - --��< - --- ---.-. __ _ _ _- Emergency Telephone No. <br /> 1 __ <br /> Contractor Licence No. _ ��� <br /> p - -- <br /> Applicants Name (Print) Title JI`�S1G .,-- -- Date- _ 7_ _ <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. <br /> - .--...- __ __- CAL. License Renewal No.____._ <br /> Capacity _ _ Gal.,Weights & Measures No. . _ <br /> Equipment Parking Address _ _ <br /> 2. ❑ PUMPER YARD - — — — --For July I __ June 30, 19 _ <br /> No.of Vehicles Stored <br /> No, of Chemical Toilets Stored <br /> 3. ePERCOLATION TEST --— - —Y - ---- <br /> R.S. or R.C.E. Name — _ _ — _. _ _ _ _ R.S. or R.C.E. No. <br /> Test Location _SSG —__ 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 /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 _,,,,— . <br /> Type Construction _ — Disposal Site____ �. <br /> No.of Units — Equipment Storage/Cleaning Location(s) . <br /> S. ❑ 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 I have prepared his application and that the wor ill be done in accordance with San Joaquin County <br /> ordinances, state laws. <br /> APPLICANT'S SIGNATURE X - —. .—. TitleCC - _— Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 0 ANNUALLYC1PER UNIT ElPER S4TE El EACH ❑ January 1 3 Received By January 31 ❑ July 1 6 Received 9y July 31 <br /> —.-... _.- .�.-..... REMIT <br /> I BILLING REMITTANCE f AMOUNT OUE CHECKED <br /> EASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> FEELESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Y �� .. <br /> cawed ay Dat61 Receept No — Permit No Issuance pate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16011 E.HAZELTON AVE.,P.O.Sam 2009 STOCKTON,CA 952011 <br />