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Applications Will Be P.`,.ssed When Submitted Properly Completed. Be S,,.wTo Sign The Application. <br /> APPLICATION - <br /> /yV (For Non-Transferable, Revocable, and Suspendable) M ( n`f <br /> S I11 I ENVIRONMENTAL HEALTH PERMIT �'f,R�_tL K��� <Z- <br /> LIQUID WASTE ' <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> A Business Name (DBA) Address <br /> z Ownersl8lYL _ty� .3c�Yr� LIh' �rtT Address =�� � 1v�_I� rl �,Z, _ <br /> a <br /> F �� Telephone Numbers c` G,� %Z� t 1 `� , �`�6T A AI-1 � ` r\ <br /> I Business Telephone No. —_ Emergency Telephone No. <br /> Contractor Licence No. <br /> 1r- <br /> Applicants Name (Print) 1.VAL-`1��'- � . >'-v;=="11_: Title _C=t'v t' .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 /> Description(Make/Yr., Color) - _ _ _ _ (�-�"�i-1 3 c, <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 _ n <br /> No. of Vehicles Stored <br /> No of Chemical Toilets Stored_ <br /> �r t�•y Fj�T�ry z - <br /> 3. PERCOLATION TEST `-; h'LIF�n1t•11t <br /> R.C.E. Name 'vyrPAL" -' £- �_�;k-1'i�; _ 1448:.-tTr R.C.E. No. I I� •tet' <br /> Test Location Test Date/Time �_ T <br /> 3. 11 SANITATION PERMIT -rEC=�'�E\-� <br /> �� ,\,:,i fi I . �� ���•��' l..�t 1 �-c J'-"t_ t � - ? (�� <•� 1 <br /> A. _ �- P l � <br /> Job Address/Location _ _ Vr I J-.1 c <br /> Owner - t` F= Address---- <br /> D <br /> ddress—❑ 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 2�j <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. 1:1 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 /> 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 l t Lf 4�L� Title iY I—� �'-�1 N� - Date <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 /> REMIT <br /> BASE E%PLANATION BILLING REMITTANCE s AMOUNT DUE CHECKED <br /> DATE DATE REMITTED ,[7 AMOUNT <br /> f FEE �'D ��(O / ✓CO ✓��_ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ce'ved by ale > 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 />