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Applications will tse rrocesseo wnen auomureu r�vyruy �.vu.Y�cicu. .+c .�..,� ....,.y.. ...� ^rr••--••--••• <br /> APP_ICA i ION <br /> (F Ion-Transferable, Revocable,and Suspendable) L SEPTA.uc <br /> 4NVIRONMENTAL HEALTH PERMIT `-00' <br /> LIQUID WASTE <br /> Application is hereby made to carry on business fn the jurisdictional area of the an Joaquin Local Health District <br /> `Isiness Name (DBA) _ i4 2l .-f t`:Si<in! Address , x /-;/5?2 <br /> Owner Address <br /> rm Partners, Addresses and Telephone Numbers OC <br /> `jsiness Telephone No. a 7 Emergency Telephone No. G , <br /> Dontractor Licence No. Z.7 5<3 !— <br /> Applicants Name(Print) Z Title Date 7 <br /> ease check Applicable Category(1-7)and Fill in the equired Information <br /> hP ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Q 1 <br /> For July 1, June 30, 19 Disposal Sites jam' <br /> escription(Make/Yr., Color) <br /> vial NO. CAL License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> quipment Parking Address <br /> ❑ PUMPER YARD <br /> *or July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> o. of Chemical Toilets Stored <br /> t. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S.or R_C.E.No. <br /> —est Location Test Date/Time <br /> SANITATION PERMIT <br /> Yrr <br /> Job Address/Location z <br /> Owner /2 e4-7=Z5 Address <br /> SEPTIC TANK ❑ CESSPOOL IV LEACHING FIELD N*SEEPAGE PIT ❑ PACKAGE PLANT <br /> ling PERMANENT ❑ TEMPORARY MINEW ❑^REPAIR r ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 f ` <br /> .ype Construction Disposal Site ]�J <br /> Jo. of Units _ Equipment Storage/Cleaning Location(s) <br /> r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name — _ Where Certified <br /> 'lant 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 /> Homeovis>_rori:c9n ed3^r^i'S €glta' scarf'{;a,--s,,. ,;ao•� ii`�,H'Ai,!hf,n"' <br /> flr n^Pt!!hrvar> f0.'4rhi;hthic ar S c r t rc <br /> I!. mit i,is._u..d,lshallnotema:oyanyperton <br /> in such marine.-.•.s t0 beCr .h-_rr• nr..n _ - ,!f;ali. .,;? <br /> Contractcr's hiring or Rg. 1 i,3s..;?he periJr 1 ;IGC Oi the 1°'c5k for which this permit is issued.I shall t <br /> employ perso;.ss:.n1ecl 19. _ f ,_ .._ :aws 6f <br /> r.. <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, and rules and regulations a San Joa in Local Health District. <br /> \PPLICANT'S SIGNATURE X _ Z <br /> .. 03 ** <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 /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 1.r OTHER <br /> Received by Date Receipt No. Permi!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 />