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' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The,Application. <br /> APPLICATION :� f f ''� "` __3 <br /> ' (For Non-Transferable,Revocable, and Suspendabie) SEP AGE <br /> ENVIRONMENTAL HEALTH PERMIT ._ - .� <br /> LIQUID WASTE C < <br /> Application is hereby made to carry on usiness in the jurisdictional area of the San Joa uinf Local Health Distric�� t <br /> }V.A-;i ie E x c r, Address <br /> w Business Name (DDA .-� T �►=-5-•--*-� <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone NO. _-__�Qo7 - Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> Applicants Name(Print) S fit- �. M Title �+"4 �_ �L�_P� -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 /> bescripfi6n(Mak'e/Yr—,Color) <br /> Serial No. CAL-L-Icense No,. __ CAL.License Renewal No. <br /> Capacity �� _ L Gal., Wgightts,&MEasures No. <br /> r <br /> Equipment Parking Address, _� _ _ ..,. - .�-•�.....r.----- --.�-•- <br /> 2. EIPUMPER YARD <br /> For July 1, June 30, 19 I <br /> t <br /> No.of Vehicles Stored <br /> No.of Chemical Toilets Stored ! { <br /> 3. 11 PERCOLATION TEST <br /> R.S.or R.C.E. Name4 R.S.or R.C.E.No. <br /> Test Location <br /> f ! est Date/Time 1 <br /> 'rr <br /> 4. gr'rA-NITATION PERMIT-; <br /> Job Address/Location <br /> ` <br /> Owner Addre <br /> SE �>f2o V ' <br /> f s ' <br /> ❑ PTIC TANK ❑ CESSPOOL Er—LEACHAG FIELD*' CC3 S EPAGE PIT ❑ PACKAGE PLANT 1 <br /> Q- fRMANENT ❑ TEMPORARY ❑ NEW � �°`BIREPAIR 11 OTHER ; f <br /> S. 0 CHEMICAL TOILETS For July 1, -June 30, 19 ' <br /> Disposal Site <br /> Type Construction I <br /> No.of Units Equipment Storage/Cleaning Locations} <br /> 6. 11PACKAGE TREATMENT PLANTi For July 1,_-June 30. 19 ; Where Certified i - <br /> Operator Name <br /> I! . <br /> Plant Location -hri' <br /> Plant Capacity I No.Units Served 4 ; 0i <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 r yif <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. I <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby,cartify that I have repared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,a s and regulati sof the S aquin 1 He th District. t I 4! <br /> APPLICANT'S SIGNATURE X f �" <br /> V r <br /> t� y+ <br /> _�, Oh bEPARTMENT'USE ONLYi�`*-'� ) k �� -s► -j <br /> �c. <br /> Jly t d Received By July 31 <br /> Fee IS R <br /> Due' 0-ANNUALLY ❑ PER UNIT ❑PER SITE ❑ EACH ❑ January 1 &Recerved By January 31 i ❑ u <br /> REMIT <br /> s - I _ $„ CHECKED <br /> tt BILLING ++ -REMITTANCE AMOUNT DUE a i <br /> PLANATION=� DATE —DATE "' -REMITTED AMOUNT <br /> -7EX <br /> O <br /> t <br /> FEE <br /> fLESS I ? <br /> ' PRORATION <br /> PLUS <br /> PENALTY i <br /> ,f OTHER i p <br /> OTHER <br /> 11 _ lr_ <br /> 1 , �`.� � ss ce D to Mailed Delivered <br /> Received by ,Date Receipt NoPermit No... � AVE.,P.O.Boy 1009 •STOCKTON,CA 95201— <br /> F• •--.�,..,.-..,r'eETrroN nl I ctIPICS TO:'�"ENVIRONMENTAL HEALTH PERMIT/SERVICES1601 E.H <br />