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Applications Will Be Proces When Submitted Properly Completed. Be Sure ;ign The Application. <br /> APPLICATION Nts--4 <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> siness Name (DBA) __ -_ - - Address._ _ _ — <br /> mer— MDEtn NU AFt_-ry_ _ _ __- Address PiC>P.,I rN_,8N't5�� ("R 95: 3� <br /> m Partners. Addresses and Telephone Numbers — r'HnN F <br /> siness Telephone No. _ —____ Emergency Telephone No. _— <br /> ntractor Licence No. — <br /> plicants Name (Print) �&AUZ- ME C LJ kZ t':�,____ Title c 6V IL EW!C-4 I N E'F-R Date- - <br /> lose check Applicable Category (1-7)and Fill in the Required Information 418 MATrt-kSW PL_A77-A <br /> ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Lot>l CA A .95? 4<5 <br /> r July , June 30. 19 Disposal Sites <br /> scrlption(Make/Yr., Color) — <br /> rial No. - _ CAL License No. CAL.License Renewal No. <br /> pacity _ Gal..Weights& Measures No. ---- <br /> uipment Parking Address — <br /> ❑ PUMPER YARD <br /> r July 1,______ June 30. 19 <br /> I. of Vehicles Stored _ <br /> I. of Chemical Toilets Stored_ A-is MA <br /> PERCOLATION TEST l.C'fll,C/�- j2�4'O Zo91 � t5 7 -- <br /> beIr R.C.E.Name \ f0,:i lc2 r Gu Pm S R.S. or R.C.E.No. <br /> st Location Fk�'V L- it-1ROP —C^U -_ Test Date/Time YyS b, EM LnY <br /> ❑ SANITATION PERMIT (SEE LO'-N-notl. MAP 0104 PARC3vs,4 <br /> b Address/Location REY� ►�'� _ ___— VKEDty SDA 4-- t"9 Z 1'.-:30-3`.00 PM <br /> vner _ Address _t?AR�Ei- 1.105 i g Z <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT V`4Z4�` <D A It - 3-3 I-92- <br /> PERMANENT <br /> 2PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER PA{_c'EL Ncfs . 1,2-,3 4- <br /> 0 CHEMICAL TO111.ETS For July 1, -June 30, 19 <br /> pe Construction - _ Disposal Site <br /> of Units _ Equipment Storage/Cleaning Location(s) <br /> ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19_ <br /> )eratorName - -__ ____ ___-- - Where Certified <br /> int Location _- —_--- -- <br /> ant Capacity __ No. Units Served <br /> ❑ LAUNDRY For July 1,-June 30, 19 <br /> ZE ❑ Less Than 1.000 Sq.Ft., ❑ 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 <br /> ordinances, state laws <br /> 3 31 -yam <br /> ,PPLICANTS SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fe*Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Rwmveo By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION 81LLINGREMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Gyt� t01� `+u��.L+� � - / 2-t�^�I �Z -2V. <br /> LESS <br /> PRORATION - — <br /> PLUS <br /> PENALTY -__- --- _--- ---._- -- <br /> OTHER -- - -_ -- - -- - — - -- ----- — <br /> OTHER <br /> _ 331-52 - <br /> Recely 0y Date Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT-RETIMN AU COPIES TO ENVIRONMENTAL HEALTH PERMIT/SERVICES 1001 E.HA2,ELTON AVE..P.O.Boa 2009 STOCKTON,CA 95201 <br />