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APPLICATION <br /> (Foy Non-Transferable, Revocable,and Suspendable) <br /> �VIRONMENTAL HEALTH PERMIT <br /> 6. LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> I Isiness Name (DBA) Address <br /> Avner 'I--, _% - Address�o —14 f4J,%0014�� , 6L�1li,C(—j <br /> Firm Partners, Addresses and Telephone Numbers 0 /t r r�^l _ <br /> 1 isiness Telephone No. Emergency Telephone No. �Qn � <br /> 1 Infractor Licence No. vC <br /> }Cpplicants Name (Print) fl Title Date <br /> 1 <br /> Please check Applicable Category(1-7)and Fill in the Required Information � <br /> ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> rsr July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> orial No. CAL.License No. CAL. License Renewal No. <br /> pacity Gal.,Weights&Measures No. <br /> Equipment Parking Address <br /> ❑ PUMPER YARD <br /> nr July 1, June 30, 19 <br /> Wo.of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> ❑ PERCOLATION TEST <br /> r,S.or R.C.E.Name R.S.or R.C.E.No. <br /> Test ocation Test Date/Time <br /> SANITATION PERMIT <br /> ,b Address/Location <br /> 16wner 14#gg4i/� aYly 1 z Address'-s'`'t d �e fit. J <br /> SEPTIC TANK ❑ CESSPOOL X,dLEACHING FIELD 11 SEEPAGE PIT PACKAGE PLANT �J <br /> I PERMANENT ❑ TEMPORARY CKNEW ❑ REPAIR ❑ OTHER /cgMt 5e�.� <br /> w 11 CHEMICAL TOILETS For July 1,-June 30, 19 - /0& �C(+ O <br /> Type Construction Disposal-Site 0-334 )D6 <br /> o.of Units Equipment Storage/Cleaning Location(s) <br /> .. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 - <br /> Operator Name Where Certified <br /> plant Location <br /> ant Capacity No. Units Served <br /> Y ❑ LAUNDRY For July 1,-June 30, 19 (1 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 1 DRY CLEANING, Chemicals Used/Amount/Mo. C <br /> w <br /> ,,a Rome owMrorlicensed egern's signature eertifiestbafaftavinl-I certifytbatin theperfamance ofthewerk forwhich this permit is issuee.!shall net employ any person 1 <br /> in such manner as to become subject to wor c:+an,.orpensati.=i jaws^,!raiinrni. <br /> eonirxtor'5 hiring or 9ub-connmting signature cerufws tine following: "i certify that in the padormarse of the work for w '4ii ti..yarmit is issced.I aha;! <br /> employ persors subject to workman's compersabon laws of cald�mia' <br /> r, I hereby certify that I have pr ared this applicat nand it t work will be done in accordance with San Joaquin County <br /> ordinances,state la d r es and regulatio Of the S Jo in Lo H h District. <br /> PPLICANTS SIGNATURE X <br /> r <br /> FOR DEPARTMENT USE O <br /> T FM IS Due: ❑ ANNLIALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> T LESS <br /> PRORATION <br /> PLUS \ <br /> PENALTY <br /> 7 <br /> OTHER <br /> OTHER <br /> T m � i �0. t E`No <br /> Received Dy a Receipt No. Permit No. Issuance Date Mailed Delivered <br /> — APPLICANT—RETURN ALL COPIES TO.. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 3009 STOCKTON.CA 9=1 <br /> r <br />