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Applications Will Be Pro sed When Submitted Propeny uompteteo. oe a t W'Mewl. ...�.+rr••��••�• <br /> �+ APPLICATION <br /> �..P (For Non-Transferable, Revocable, and Suspen ) 9,1 �cpG <br /> ENVIRONMENTAL HEALTH PERMIT IY 1 0 <br /> LIQUID WASTE <br /> Application is hereby�tckcarry o;business in the jurisdictional area of the San Joaquin Local Health Dirstrict <br /> sx �j �lxi Address �e?i� -`'NMAL A-v�C - <br /> m4t� 6A <br /> y Business Name (DBA f0��7 p;, ' r 5 L/^1l1 OAIr—S D�//�A <br /> i Owner ( t/w,�(t•�� h - FhE?l.� S _, ddress I _ <br /> Y Firm Partners. Addresses and Telephone Numt, s ---- <br /> Q. Business Telephone No 35- 2 -- _ - - Emergency Telephone No. - -- --- <br /> Contractor Licence No - - Z <br /> a <br /> Applicants Name (Print) �+�'T L.� -�•" Ae - Title �lw� -� 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 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 <br /> For ",uly 1 June 30, 19 <br /> No of Vehicles Stored - - <br /> NoChemical Toilets Stored <br /> o -_ - - - - -- <br /> 3. �PERCOLATION TEST <br /> R.S.or R.C.E. Name /�� f'' �L'f��di 4/C. R.S. or R.C.E. No. ��� <br /> Test Location - Test Date/Time <br /> 4. 11SANITATION PERMIT M5 J �2 O <br /> Job Address/Location <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 SiteNo. of Units Equipment Storage/Cleaning Location(s) - -- - -- - - - -- <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name -- <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 thi 11 application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. <br /> X -_-`�-" L G� --- - - - Title vj�G Date - <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑July 1 A ReCo d By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING qCE AMOUNT DUE CHECKED <br /> Y DATE TTED AMOUNT <br /> FEE I J v �rxL « ---- — -- <br /> LESS 3a 19k <br /> PRORATION <br /> PLUS _ ---- <br /> PENALTY _ <br /> OTHER OTHER — <br /> R eryDy <br /> Date Receipt No Permit No issuance Date Mailed Delivered <br /> l APPLIA1601 E.HAZELTON AVE..P.O.Boa 4009 STOCKTON,CA 95401 <br /> APPL ANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />