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Applications Will Be Pr ;sed When Submitted Properly Completed. Be F To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) V:5- 9Z,- 1 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Address <br /> i Owner V , ''t=om CANc.i L1-Fi_ Address <br /> J Firm Partners, Addresses and Telephone Numbers — <br /> aBusiness Telephone No Emergency Telephone No. <br /> Contractor Licence No <br /> Applicants Name (Print) __=��_ t ��iy_ i=a -__ _ Title e- IWtlk Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information GG 11 <br /> 1. C3 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4.1S M;T*W' PWZA <br /> For July 1, _ June 30, 19 Disposal Sites )`Offal lQA 954.4-n <br /> Description(Make/Yr., Color) _ _ _�_� i _- <br /> Serial No CALL License No. __- __ CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> 1 <br /> For July 1June 30. 19 L F'f��•E�.S <br /> No of Vehicles Stored <br /> No of Chemical Toilets Stored---- <br /> 3. <br /> tored_3. © PERCOLATION TEST it (8 MP71 11'E .TV,,P,,-ZA �� v t� �.;�- 9 S Z4-+ � ( n 159 <br /> Wg.er R.C.E. Name yj1 .6;j1`R r. Gr• iJ W R.C.E. No. i i5a4- _ <br /> ?est Location 12947AF.I.&E1RC U L_rQl_C 14ZiTest Date/Time WIU- CALL-Tn =­ClFIX/L -� <br /> 4. ❑ SANITATION PERMIT (:>E'F (`tAF ("4 ZItD>E a;r -T+Ak5 SHsp--T S <br /> Job Address/Location _ 6 <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) <br /> 6. ❑ 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 lam` <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo <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 /> APPLICANT'S SIGNATURE X Title 4"V-L Date--2 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH AMOUNT DUE C <br /> CH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING T REMITTANCE $ REMIT <br /> ASE EXPLANATION _ — HECKED— <br /> DATE <br /> �-- DATE � REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS - - -------- -- -------- <br /> PENALTY _- <br /> OTHER <br /> OTHER <br /> R e ed by ate Receipt No Permit No Issuance Date Mailed Delivered <br /> Xw <br /> APPLICANT-RETURN ALL COPT)M T ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON.CA 95201 <br />