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<br /> S §. w•" AppueeNonc Will Be Processed When Submitted Property Completed.Be SLlre To Sign The Appl ati�r� C�' `r
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<br /> 'f�, APPLICATION '
<br /> *� (For Non-Transferable,Rav_cable,and Suependable)
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<br /> ENVIRONMENTAL HEALTH PERMIT ScP TAGE ` . ��
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<br /> LIQUID WASTE
<br /> *� Application i ereby m;,,,Clr ry an usin ss in he ju ' dictionaf area of the n Joa uin Loca!Health Ditt
<br /> r8uslness Name A r�5 g)-�CL ^f" ' Address57
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<br /> ��Owner °•.• " d•L'._--- Address
<br /> s.,g:Flrm Partners.'Addresses and 4 n*' �ISIr sus Telephone Numbers.---______
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<br /> bers—.—_— -- —
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<br /> B;" Telephone No.� 'rl G�-rEmergency Telephone No. ` r
<br /> -Contractor Licence No
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<br /> „TL,Applrcapts,Name(Pnnt)^• � —� _TitleDate_
<br /> r ,,,,Please check Applicable Category(1-7)and Fill in the Required Information
<br /> * 1."❑ PUMPER VE
<br /> HICLI'AERMIT REGISTRATION(FOR EACH VEHICLE) )
<br /> For July j:: J6n9 30,19 Disposal SitCs
<br /> X.a-'fOescription(MakeNr. Color)
<br /> 3Serlal No. "'
<br /> CAL.License No.
<br /> �CAL.License Renewal No, �-
<br /> ry`Capaclly ` t — Gal.,Weights&Maasures Nor
<br /> 7 Equ(prilimt Parking Address �. r ±
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<br /> '2. i PUMPER YARD
<br /> i slY Far Jufy 1,` June 30,19 _
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<br /> No.,of Vehicles Stared
<br /> &No.JoiChemical Toilets Stored
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<br /> 9 3."❑'PERCOLATION TEST F
<br /> y% #€'R.3 or R.C.E.Name R.S.or R.C.E.No. s �
<br /> PTes4 LyG�aiion:' _ Test Dale/Time 7� 4
<br /> r 4; SANITATION PERMIT
<br /> shy'"Jori Address/Loc Ion 1 .37 / ,t1 — f tri F S ✓��. y�y>y
<br /> ),?t:OwnerZ Address
<br /> (� 8❑'SEPTIC.TANK ❑ CESSPDOL < LEACHING FIELD 0--rEEPAGE PITY ❑ PACKAGE PLANTr
<br /> f# ©.PERMANENT, r ❑ TEMPORARY .;' ❑,NEW ❑`FfffPAIR ❑ OTHER 1•
<br /> £ 5 r❑ CHEMICAL TOILETS For July 1,:-June 30,18
<br /> 3;-'r a Construction .. i 'r..r rti� t7r I
<br /> : YP Disposal Site ;
<br /> dy't No.of Units— Equipment Storage/gleaning Location(s)_ #i
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<br /> PACKAGE TREATMENT PLANT For July 1,-June 30, 19 ��
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<br /> #,Operator Name Where Certified' " ,`,�
<br /> { Plant Location —, l. `
<br /> t Pian,CIPacity — _No. Units Served
<br /> Ar. r 7 ;[,j LAUNDRY-'For July 1,-June.30,.19---
<br /> ;3;,)SIZE ❑ Less Than.al,000 Sq Ft, �4 More Phan 4,000 Sq.Ft.
<br /> ❑ DRY CLEANING.
<br /> t1�, G,Chemicals Used/Amount/Mo
<br /> Y, k I hereby certify that I hav¢'p�epared this application and that the work will be done in accorc�tnfd�with San Joaqum,Count�
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<br /> t,s v ordinances,state laws,and rules and ulations of the San Joa uin Local Health District.
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<br /> r-APPLICANT's
<br /> SIGNATURE X 't.
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<br /> FOR DEPARTMENT USE ON Y '
<br /> Fee Is Due:❑ ANNUALLY [I PER UNIT — ❑ PER SITE ❑ EACH © January J.N ceired By January 31 ❑July 1 8 ReteivcW 8y Juty 37• y
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<br /> BASE EXPLANATION BILLING REMITT CE E
<br /> CAT"E DAT REMITTED� AMOUNY OUE g1IFCKED
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<br /> �y `"I��`. � � FEE':: � � •�-. ,�� j,�a c s,��;�tic��
<br /> r£ � PRORATIUN
<br /> . t1 1'r PLUS
<br /> la � •PENALTY
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<br /> OTHER
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<br /> ��' rieceWytj Oy : Oats i Receipt No. - pwind o 135uance Uaia Meilrb .t•-
<br /> elWrod
<br /> {l$ `APPLICANT—RETURN ALL COPIES tp; ENVIRONMENTAL HEALTH PERMIT/SERVICE$ 1601 E.NAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 05201� sL�.-«��.
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