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Applications Will Be Pr sed When Submitted Property Completed. Be To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r LIQUID WASTE <br /> Application is hereby.mad to carry onn,business in the)udictional area of the San Joaquin Local Health 9istrict <br /> H Business Name (DBA) I� r r {�_SS(C 1 Cif S Address <br /> i Owner Ed i_i. J r �r d—p — Address <br /> --- <br /> vlc-� ` <br /> J <br /> Firm Partners. Addresses and Telephone Numbers <br /> aBusiness Telephone No _ _ _ _.-_ - Emergency Telephone No.----.- <br /> Contractor <br /> o.--_._Contractor Licence No. -Date}�[�f"'177 __. Date_ 6— " 92 <br /> a Applicants Name (Pant) STD/� �'S!)/ C/ Title -._- - <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) — <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. A PERCOLATION TEST 3 C� <br /> R.S. of r+C&. Name " L11�?/I - -- - -- R.S. or .CC No. 17, 5__ <br /> Test Location 2 2 - j C. AU-, �� - - Test Date/Time- -� -3 'G� ---- ------ -- - <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/LocationOwner - ___--. . __ _-. Address -- - --- <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER Al /� <br /> 5. 13 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 <br /> SIZE ❑ Less Than 1,000 Sq. Ft_ ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. -- - -- - --- -- - / <br /> r <br /> JJr <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> GC, <br /> ordinances, state laws <br /> APPLICANT'S SIGNATURE X -1L� Title Date !FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 3 Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 1 DATE DATE REMITTED AMOUNT <br /> FEE 0 d0 � hOIP Q. /? - -- -- <br /> LESS <br /> PRORATION —__ — ---- - <br /> PLUS <br /> PENALTY --- - ---- <br /> OTHER <br /> OTHER I __ -- - - -- ---— - <br /> 71 <br /> Receby Date Receipt o Permit No Issuance Date Mailed Delivered <br /> LICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bo■2009 STOCKTON,CA 95207 <br />