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mppuuauuns wou oe rrocesseu wnen auomnteu rropeny t ompleteo. ee aufe to at9n I ne Appncauon. <br /> APPLICATION �, <br /> L �or Non-Transferable, Revocable, and SuspendamE) <br /> ENVIRONMENTAL HEALTH PERMIT _Q7 P-. <br /> LIQUID WASTE <br /> t A lication Is ereb� mad o car on bu�j ess in t urisdictional area of the San Jf� uin Local He h Distric <br /> �aBusiness.NaTe (DBA) DZ o/k-� I Addres� /ter U �(' � <br /> z Owner Address "� !- �C• /�•+- fx / 6OZ47 2i, � <br /> I -irm Partners, Addresses and Telephone Numbers �Gr�r+L . £�E 7✓J��3� <br /> 1!..3usiness Telephone No. 3h S_--jSj� Emergency Telephone No. <br /> Contractor Licence NO. ��S_7�/ - <br /> 1pphcants Name (Print) oz, Title da-1 Date 7 7� I <br /> 'lease check Applicable Category (1-7)and Fill In the Required Information <br /> _ (,(� <br /> ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) of <br /> For July 1, June 30, 19 Disposal Sites W <br /> description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> -quipment Parking Address <br /> ...!. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> Vo. of Vehicles Stored <br /> Jo. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Feat Location Test Date/Time <br /> Ma <br /> •. SANITATION PERMIT <br /> Job Addres /Location +?7+ZQ-'i �V' �� � �— � gcf (52�. - <br /> Jwner ZZ4,r� Address �5-,r � d- rr�r./�-i_ _ <br /> SEPTIC ANK ❑ CESSPOOL D"LEACHING FIELD U-fEEPAGE PIT ❑ PACKAGE PLANT J <br /> ERMANENT ❑ TEMPORARY ®NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> `No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ ,PACKAGE TREATMENT PLANT For July 1, -June 30, 19 .Z <br /> Dperator Name Where Certified <br /> ee.'lant Location <br /> Plant Capacity No. Units Served <br /> r. Cl LAUNDRY For July 1, -June 30, 19 <br /> 3IZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> DRY CLEANING. Chemicals Used/Amourl <br /> I hereby certify that I have prepared this ap lication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ru and regul o the San Joaquin Local Health District. <br /> r APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By ly 71 <br /> j, S RE <br /> ilr BASE EXPLANATION BILLING REMITTANCE PATE DATE REMITTED AMOUNT DUE CH ED <br /> T <br /> FEE 1,4S <br /> � �yNv <br /> LESS <br /> PRORATION A <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER r <br /> iecemed by Date Receipt No. ermit No. Is uance pale Mailed Delivered <br /> t__! APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1 Wf E. AZELTON AVE.,P.O.Bot 2m STOCKTON,CA ISSNI <br />