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Applications Will Be ;essed When Submitted Properly Completed. Be_e To Sign The Application. <br /> APPLICATION p <br /> (For Non-Transferable, Revocable, and Suspendable) S�r� 7 2-I 9 <br /> ENVIRONMENTAL HEALTH PERMIT 'Z FAkc-EL j <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) _ Address-------------- <br /> Owner <br /> ddress_— - _ __-_Owner 10HNLsl..._ 1GCLd�_ Address$Q45_F=A=7- REIZ:iERR�AD__.T&CAMSb� __ O <br /> Firm Partners. Addresses and Telephone Numbers Z-09) <br /> Business Telephone No. -_.____.__ _______ Emergency Telephone No. <br /> J Contractor Licence No. <br /> Applicants Name (Print) WALTEP, E ' ka i z, _ _- Title Gi)(IL ENGttAEFR Date _11-an-9 _ <br /> Please check Applicable Category (1-7) and Fill in the Required Information C� *11 Sal 4- <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4-(8 IIIA-"Ew PLAZA <br /> For July T, June 30. 19 Uisposai SitesLaCi t CA. 9524-0 <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 Ms-9Z-19 <br /> For July 1 _ -- June 30, 19 _- ZPARCELM- <br /> No of Vehicles Stored <br /> No of Chemical Toilets Stored <br /> 3. )KPERCOLATiON TEST Ew p1_AZA1 LoDi,C�. 5 <br /> gdkmLR.C.E. Name )NAt- 'E`fZ_�C.I�R'L1S 'R*AwR.C.E. No. <br /> Test Location A--Ass VAELM ik lRin Al Test Date/Time _ RK n Z <br /> 4. ❑ SANITATION PERMIT AGAMF'�JCA. 9522-CI, i1T1b• RJE^r;loGi <br /> Job Address/Location �sIEE._ FL-.F- 51DE Fo-9-- OVA MAP) (1-2"9z, WEMM--DA <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 /> L <br /> Plant Location -�d- <br /> Plant Capacity _ .- No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19.---- <br /> SIZE: <br /> 0, 19._ _SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/AmounVMO. <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 /> APPLICANT'S SIGNATURE X Title 0,fil_ Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t &Received By January 31 ❑ July 1 &Received By July 31 <br /> 1 —- - T- REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE -� �{! e0� 11-3u-Qt l� ' a'�L �J *. 'D v.31 v <br /> LESS <br /> PRORATION <br /> PWS—___-- � <br /> PENALTY <br /> OTHER - --- -- -— - - <br /> I <br /> OTHER <br /> L Op <br /> Re ven e, Date Receipt Nom-� Permit No issuance Date Wiled Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E HAZELTON AVE.,P.O.boll 200Y STOCKTON,CA 05201 <br />