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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) 1'1- <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE 2 <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Bt#woes Name (0" F-- SRA NGES H Address <br /> Q Owner AE S i�1='TTI _ Address i7 LCo(o JCS. �� (t IE G-UL (ZT SCA�th Cp9532D <br /> u Firm Partners, Addresses and Telephone Numbers M09)$3f3 <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants Name (Print) WAt_'Trn-GZ t:-- C oRT15 Title cIYIL- TtACmIDate <br /> Please check Applicable Category (1-7) and Fill in the Required Information C' •# ►1584- <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4)BM Fr't'TF1 EYY PzA, A <br /> For July 1, June 30, 19Disposal Sites t-0p I ) GAi-I FORM F, !)S <br /> Description(Make/Yr., Color) _ _ ( ot)) 56z B- 4i sg <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 MS_ , _74- <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored E PL67_k PAfy_C L:5 <br /> 3. 0 PERCOLATION TEST 1�5a l�C PSI-1F01�'N I F+ 5Z <br /> (209) 3e-8- 1••1 <br /> A,&;:�R.C.E. Name WA i,_TSR C U RT►n R.C.E. No. i l 5<�b 4- 12-6 <br /> rt. I <br /> Test Location 177Sp S7T )t4E<34JL_ RD. Test Date/Time k 2 <br /> 4. ❑ SANITATION PERMIT E-_-_-C_AU!>R/CA 9532© r nA^ <br /> Job Address/Location (ZCOi_AT1�1� <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER S�pE AP <br /> 5. C3 CHEMICAL TOILETS For July 1, - June 30, 19 tj- <br /> Type Construction Disposal Site <br /> No of Units Equipment Storage/Cleaning Location(s) _ � z'Tl*-: £__ Ty <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. ❑ 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 Title Date �- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE JREMITTED �} AMOUNT_ <br /> FEE ' ��-s �.�-5-- <br /> LESS <br /> 5 LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTH <br /> Received by Date 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 />