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rrocfes�seo wnen *uAPPLICATIONp1etea. Ise sure"ro 5111r,The App ltcatlon. <br /> rSKI or Non-Transferable, Revocable,and Suspendabl" <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SAME!)�-�; LIQUID WASTE <br /> fi i Application is hereby made to carry business in the jurisdictional area of the San Joaquin Local Health District <br /> Ii .Business Name (DBA) '& {.` • Address r37S Lk)', n A jm; _.,__ <br /> a Owner Address 457 S L[7 i /!a c cs O o .A. -Dr-, _ <br /> U Firm Partners, Addresses and Tele hone Numbers <br /> ;Business Telephone No. <br /> L Emergency Telephone No. 1 <br /> FFFztontractor Licence No. cll� <br /> a Applicants Name (Print) ;s�t�t/ro, L_ Q]!,f r'1 Title [?IJ LN� _ Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> �1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites _. <br /> r—Description(Make/Yr., Calor) <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 — 7 <br /> y3- El PERCOLATION TEST I� <br /> R.S. or R.C.E. Name R.S. or R.C.E, No. i <br /> Test Location Test Da ima <br /> F; SANITATION PE NIT <br /> J }�� f 'w <br /> _ ob Address/Location L ►'1 <br /> -Owner — e n r .sm.fithk�aI6ress &i 41,6 rC- <br /> f--+❑ SEPTIC TANK ❑ CESSPOOL' XLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLAN <br /> Lk'PERMANENT ❑ TEMPORARY ❑ NEW XREPAIR 19 OTHER <br /> "5, ❑ CHEMICAL TOILETS For July 1, -June 30, 19 yxjr/ l� <br /> Type Construction Disposal Site <br /> FNo. of Units Equipment Storage/Cleaning Location(s) _ <br /> 6. 13PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> Operator Name Where Certified <br /> [—Plant Location <br /> F 'Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> 1, SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 11,000 Sq. Ft. <br /> i ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> t � <br /> _d I hereby certify that I have preps th' application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule d r latians of th an Jaaqu' Local Health District, <br /> APPLICANT'S SIGNATURE X ~ <br /> it <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 July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> I DATE DATE REMITTED AMOUNT <br /> i <br /> FEE G, O <br /> LESS <br /> PRORATION r� <br /> PLUS <br /> �.� PENALTY <br /> OTHER <br /> U r <br /> OTHER <br /> Received by Dale Receipt No. Permit No. Iss ante l5ate M ed Delivered <br /> i APPLICANT--RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.. .Son 2009 STOCKTON,CA$5201 <br /> e: � WJ/ <br />