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Applications Will Bessed When Submitted Property Completed, Be To Sign The Application. <br /> APPLICATION <br /> J= (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application''is hereby rrde to carry on busiyess in the urisdictlonal area of the San Joaquin Local Health District <br /> F Business Name (DBA)��4_ U• A%Vr�trQrY 1Akic .vGAddress #I& &O1441-4f wIEC,f 21y ,17 r^ C-4 ls'avv <br /> i Owner/ver,(,- o- _Ant-_z i5. ,i_ _ _ _ Address �� ��A�Z/�� �-o��. C.4 ;1 <br /> Firm Partners, Addresses and Tel phone Numbers <br /> gBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. _ _ _ _ <br /> Applicants Name (Print) Noiy 0• �rOil' 3oQ/ Title l3eeSt _ Date <br /> Plisse 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 /> Description(Make/Yr., Color) <br /> Serial No. _ CAL License No. CAL. License Renewal No. -_ <br /> Capacity— Gal.,Weights& Measures No. <br /> Equipment Parking Address _ - — <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> No.of Chemical Toilets Stored <br /> 3. ,PERCOLATION TEST _-- <br /> R.S. R�. .. aamee �IVE/C- d. R.S. or CJ0. <br /> Test Locations m'�GIZ✓�u E _ Test Date/Time W NoTi-'Er_ <br /> 4. ❑ SANITATION PERMIT <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 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 Fo►July 1, -June 30, 19 / <br /> SIZE: 13 Less Than 1,000 Sq. Ft., 13 More Than 1,000 Sq. Ft <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 7�L <br /> ordinances, state laws <br /> Z�l _4_�APPLICANT'S SIGNATURE XU -- _— Title .�'����CY^ Date <br /> FOR PARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ZPER UNIT ❑ PER SITE ❑ EACH ❑ January/&Received By January 31 ❑July 1&Received By July 31 <br /> -- REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> /0( ,Z— <br /> LESS / DATE DATE REMITTED AMODUNT��.._QQ <br /> FEE /U. <br /> LESS <br /> PRORATION _- <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Race }ly Date Receipt No Permit No Issuance Date Mailed Delivered <br /> A�Y_�-IICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 160/E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />