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Applications Will Be Fused When Submitted Property Completed.Bef 7 To Sign The Application. APPLICATION (For Non-Transferable,Revocable,and Suspendable) '-]-11 J(, ENVIRONMENTAL HEALTH PERMIT Y/� LIQUID WASTE :2_53---(30--1,9 Application is herebylma_r7la to carry on business Ln the jurisdictional area of the San Joaquin Local Health gislftl- m Business Name(DBA) S Qf1-'Is, 'C/tet �/'I��ne rnL• Address 4045 C�hOtaod D A✓e He Owner�1 Rhh�i?_t Address -41 4113 S Traci. /�lva� Firm Partners, Addresses and TGelephone NumbJers - $ Business Telephone No. 9 c��t.y 21 Emergency Telephone No. �Contractor Licence No. _ � Applicants Name(Print) S h _--C.�4 trJ Title A�L'� 7- Date Please check Applicable Category(1-7)and Fill in the Required Information 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) For July 1, June 30, 19 Disposal Sites Description(Make/Yr..Color) - - -- Serial No. CAL.License No. CAL.License Renewal No, Capacity Gat.,Weights d Measures No. Equipment Parking Address 2. ❑ PUMPER YARD For July 1, June 30. 19 I No. of Vehicles Stored of , No.of Chemical Toilets Stored i 3" WPERCOLATION TE T r^ R.S.or R.C.E. Name Pl0 {r iL _�_� Ce loo? R.S.or R.C.E.N Test Location -3070'1 S. MacAr-Aur Dr Test Date/Timeq-2 - 9� T 1 X 30-=2�d 4. ❑ SANITATION PERMIT Job Address/Locatlon - � Owner _-. Address , ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER 5- ❑ CHEMICAL TOILETS For July 1,-June 30. 19 .. I Type Construction Disposal Site f No. of Units Equipment Storage/Cleaning Location(s) 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 . Operator Name Whom Certified —--- Plant Location F I Plant Capacity No. Units Served as 7. ❑ LAUNDRY For July 1,-June 30, 18 SIZE: ❑ Less Than 1,000 Sq.Ft., ❑ More Than 1,000 Sq. Ft. ❑ DRY CLEANING,Chemicals Used/Amount/Mo. I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County - ordinances, state laws. 1 p '7 APPLICANT'S SIGNATURE X Z .OM �it�A,7.>',(, Title Date I -�.2 93 FOR DEPARTMENT USE ONLY Fee Is Duel ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I a Received BY January at O July.I a Reeei.ed By J Wy]I REMIT BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED DATE DATE REMITTED AMOUNT FEE ---- LESS PRORATION PLUS PENALTY OTHER OTHER Recalled by Date Receipt NO. Permd Na ILHlance Dale mailed Delivem0 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT,SERVICEa 1601 E.HAZELTON AVE.P.O.aoa area STOCKTOK CA erxo !