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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) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> h Business Name (DBA) Address_ PHONE° -759-3 9 f c-i <br /> a Owner ROFsE�'P_1� CAMPEYE-I Address 214-09 S_-A__vr-- i4iG_,HWA`( ZT1= l2 <br /> Firm Partners, Addresses and Telephone Numbers /o P4- BOX 'I$4-, r t`t`mRbX=4<--es,9522'1 <br /> eBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants Name (Print) \UALTJ=-R - -tt RTIS - Title C►� L_ Date - -92 <br /> Please check Applicable Category (1-7) and Fill in the Required Information 4-tg -z-_ A <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Ln t:-I)C1i 2-4-c!) <br /> For July 1,_ _ June 30, 19 Disposal Sites _ Ucl9) 34,8- 4159' <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 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. PERCOLATION TEST „Opt/ CN- 952 PlAOrl£ <br /> fl:S70f R.C.E. Name _ L< -C l R96ow R.C.E. No. 1 <br /> Test Location 'STA�TF H jr-1}-{W&Y R-SE 12 Test Dane/Time 2:,^C <br /> 4. ❑ SANITATION PERMIT�5�� LOCATioAI 4-l - 2- <br /> Job <br /> Job Address/Location Ryl<I_-SZ�P_ Dt <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 /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19—_ g1„r <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ,, Z <br /> C3 DRY CLEANING, Chemicals Used/Amount/Mo. — _� ' 7 - <br /> 160 <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 Title1Sy IIL- EN!as I Date 3I- 5Z <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ A NT DUE CHECKED <br /> DATE DATEc� /REMrITTED AMOUNT <br /> FEE •D(� 3` ��Z �3 1 Z— l CJb -06 C9.- <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Rec iv 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 />