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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION PAVE(_ No i 4,1, <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTACE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE 91 - 91 <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) _ Address PHo141=I r-c=!�) -:; 3-n9 3-7 <br /> a Owner AIrTjj�BX ZW ILMI Lc�P>v� _ __ Address G08i 7 NANL-r RoApTAcAr-eP,0 c A�=�22a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print)WAL--TrESZ E . Q UL)R r +tsrplz; yC-,It4EEK Title S_IY�=��i l - Q Date Tu�E i�99 <br /> Please check Applicable Category (1-7) and Fill in he Requ�e�!Information 4-(4S� f�A'1'TH�It� PL-�ZA <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Lnt,L, CA-9524o <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 PA,,E . �L- <br /> 3. P PERCOLATION AUkA �'�zA}LoUI�cA 9524 i^ M5-91- <br /> 1 3(y8- '(-1� solLSurrABi�ritf 5�-<Ib�( <br /> R.C.E. Name �V jAIi <br /> � _ l)gZ'sl R.C.E. No. I a �-- <br /> Test Location 15nRI E-6=:��tiAr.t� Re-,AD Test Date/Time RR SoAV-- -TU� 1� 1I9g i <3 To <br /> 2; 30 PM <br /> 4. El ,�1, <br /> SANITATION PERMIT iZEItAG � �j� <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 For July 1, -June 30, 19 <br /> SIZE ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home owner or licensed agent's sipnature certifie-the fetlpwinp:"t certifyy that lit the prrtixmartce of the work tar which this permit is issued.I sh al l not employ any person <br /> in such manner as to be.rome subject to woraman's compensation laws 01`0 forrtia l certif that in the performance of ihF,.vork for which this permit is issued.I shall <br /> Contractor's hiring or sub-contracting signature certifies the fopowing: Y <br /> employ parsons subject to workman's compensation laws of Caliiornia.' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, <br /> /and rules and regulations of <br /> the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 7 L hR Z--,J - — <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE G DDAATE/y� REMITTED/ AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 01,9:2- <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />