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Applications� ill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. - 1 <br /> � APPLICATION _ate <br /> s ) (For Non-Transferable, Revocable,and Suspendable) EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE ! <br /> Application ishereby mad to carry on business in the jurisdictional area of the San Joaquin Local Health Dls c � �. <br /> •. Business Name DBA) !f < �!`- ' � ' . ^1 Address- <br /> 71 <br /> ddress I}�' V``- ' 7 <br /> r'. ,^. f o r '�? l'. Address <br /> Ownerry.=^'��-r.—�—cl a-+—.—.!—�R.. .. <br /> D Firm Partners, Addresses antl TBlephone NumtS6ra a <br /> +.. Business Telephone No. �� •-�7 '� r Emergency Telephone No. <br /> j Contractor Llcencili 2 it <br /> LApPlicarJts Name(P.rint) '' - ? •r"1 �-t - °'- Title Data <br /> Please check Applicable Category (1-7) and Fill in the Requifeg Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> J-1y.1, June 30, 19 ___ Disposal Sites _ <br /> Description(Mske/Yr.,Colbr) - <br /> Serial CAL. License No. _ CAL.License Renewal No. <br /> Capacity r` Gal.,Weights&Measures No. <br /> Equiprne64`Parking Address' ` <br /> 2. ❑ PUMPER YARD <br /> s <br /> For July 1," JJunE36;19`_ <br /> No. of Vehicles Stored <br /> No.of Chemical Toilets Stored t' <br /> _ 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name. ) .. _ _R.S.or R.C.E.'f Fav <br /> 4est.0ete/TilrYe� .-,.•.•,••� r �"°' ' F..I <br /> Test Location .- <br /> 4. 1:1 SANITATION PERMIT <br /> Job Address/Locatiort,� 4" i �7 - C„i7p S, A-.E --3 <br /> ass <br /> TAEPTIC TANK ❑ cE SPOOL 1' ACHING FIELD 13 SEEPAGE PIT PACT GE PLANT - v <br /> _ E3 PERMANENT ❑ TEMPORARY ' ® NEW .= 11 REPAIR 13 OTHER <br /> 4 +� <br /> 5. 11 CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction .Disposal Slte <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> f ? , <br /> �. 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name ” Where Certified <br /> -i <br /> Plant Location <br /> Plant Capacity 71, <br /> No- Unita Served -- _ <br /> 7. ❑ LAUNDRY For July 1.-June 30,19 ;,x ' <br /> SIZE: ❑ Less Then 1,OOD Sq.Ft., 13More Than 1,000'u�,q.*Ft. r�? <br /> ❑ DRY CLEANING,Chemicals Used/AmOUnt/MO. <br /> L <br /> ID <br /> I hereby certify that 1 have prepared this application•and that the work will be done in accorgapi ith San Joaquin County <br /> ordinances,state laws, and rul a regulations of th�San Joaquin Local Health District. nYV <br /> APPLICANT'S SIGNATURE Xly <br /> '/ <br /> r <br /> FOR IIEPARTMENT USE ONLY. <br /> Fee Is Due: ❑ ANNUALLY p PER UNIT ❑ PER SITE ❑ EACH ❑ nuar ecelved By January 31 ❑July 1&Rxeivad By July 31 <br /> BRA NG REMITT - § REMIT <br /> BASE EXPLANATION DATE DA REMITTED AMOUNT DUE CHECKED <br /> _ L[� AMOUNT <br /> FEE z. [V r <br /> LESS <br /> ,.PRORATION _ <br /> PLUS <br /> PENALTY 1 <br /> OTHER <br /> tt r <br /> OTHER 7 <br /> to/Sro d 5 cS 3a 90 i <br /> Reeelved by bate Receipt 1.0, - Permit NO. I rnYMile M%HW Delivered <br /> APPLICANT—RETURN ALL COMES TO: ENVIRONMENTAL HEALTH PERMITISERVICE4 tact E.HALELTON AVL,P.O.Bea 20as STOCKTON.CA NMI I <br />