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:, r.✓!:�.1"lL 44e F...:'.3' E: .'.hY.ste. i{M.t vt y `1: f 6. <br /> LIQUID WASTE ~ <br /> Application is here b ade to carryon business in the jurisdictional area of the,4an J aquin Local ealth Dis i t <br /> �, <br /> F Business Name (DBA) { ' OUS 7,�yr Address no aa�/Sd S7J ,w QSr2d <br /> i Owner Address <br /> Firm Partners,Addresses and Tel one Num ers <br /> A Business Telephone No. — Emergency Telephone No. <br /> 11 Contractor Licence No. <br /> L Applicants Name (Print) Title Dale d <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 <br /> Description(Make(Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights 8 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. or R.C.E. Name R.S. or R.C.E. No. <br /> Teocation Test Date/Time <br /> st <br /> 4. SANITATION PERM <br /> Job Addres1'LgL0on / <br /> Owner Le In R _F FJ-1 Address <br /> SEPTIC TANK 13CESSPOOL of LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY (KNEW ❑ 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. t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO. <br /> n <br /> I hereby certify that I have prepared this applicatiQlI and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and reg lations of Sian Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X lk <br /> I.,IJ <br /> FOR IDEPARTMENT USE ONLY - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑duly 14 ReceWW By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 9 <br /> LESS <br /> PRORATION <br /> PLUS / <br /> PENALTY O <br /> OTHER <br /> OTHER <br /> 33ZZ illo S 8( <br /> Receive0 by Dene Receipt No. Permit a. Iesu MeileE Delivere0 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1807 E.HAZELTON AVE.,P.O.Boa 2006 STOCKTON,CA 95201 <br />