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APPLICATION <br /> t�Non-Transferable, Revocable,and Suspendable E- <br /> � s�Pra=;� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i hereby made to car on business in the jurisdictional area of the San Joaquin Local Health District <br /> yr3usiness Dame {DBA} ddress � � Z�? <br /> za Dwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> �ausiness Telephone NO– 4(6!�2"%Stv, Emergency Telephone No. <br /> Contractor Licence No. <br /> a Kpplicants Name (Print) MmAkl�a-�e I IAs Title 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) <br /> L,Serial No. CAL. License iVo. CAL. License Renewal-No. <br /> :Capacity Gal., Weights &Meas&es,No. <br /> Equipment Parking Address <br /> 1. ❑ PUMPER YARD <br /> LFor July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored, _ <br /> 1-3. ❑"PERCOLATION TEST I R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> ��,, <br /> L.0 2' SANITATION PERMIT <br /> Job Address/Location <br /> Vpi <br /> Owner , _ CC> t/ J Address �?. � <br /> SEPTIC-TANK ❑ CESSPOOL 21LEACHING1'fIELD ' ❑ SEEPAGE PIT ❑ PACKAGE PLANT O� <br /> L"9-15-ERMANENT 11 TEMPORARY' ,,QTEW_t 11 REPAIR ❑ OTHER <br /> S. ID,`CHEMICAL TOILETS For July,1, -June 30, 19 <br /> Type Construction Disposal Site ` <br /> L-No. of Units r_ _Equipniient.Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July tl1,--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: 0 Less-Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft, <br /> 1-2 DRY CLEANING, Chemicals Lised/Arrtdurit/Mo: _ <br /> � f <br /> I hereby certify that I e prepared this ap'plicato ' nd that the wo k will be done in accordance with San Joaquin County <br /> ordinances, state law n and re <br /> at <br /> ordinances. San uin Mal Health District. <br /> 6.APPLICANT'S SIGNATURE ` <br /> FOR DEPARTMENT USE ONLY <br /> 'Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> f BASE EXPLANATION REMITTED PATE DATE RIAMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE,. 04 <br /> c <br /> LESS <br /> PRORATION <br /> PLUS - <br /> PFNAI_TY <br /> OTHER <br /> OTHER <br /> 07 D /5 <br /> Received by Date Receipt No. Permit No. qssuancd pat Mailed Delivered <br /> �+ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />