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fwpll.QUuxla Will cm r1%ILM0017u rinrn auuxnuIra rrupenr wmP1eau9.ee aure I o wgn I ne %ppucation. _ <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> y-n ENVIRONMENTAL HEALTH PERMIT r SEPPAGE <br /> LIQUID WASTE <br /> Application is herebymade to ar usiness in the jurisdictional area of the S�pgoaquin Local Health District <br /> Business Name (OBA) . ( . 1 ryL� Address •�• ��✓/ / -- _. - - <br /> Owner �G, LC�--- Address_ <br /> Firm Partners,Addresses and Telephone Numbers <br /> Business Tel ephoneNo. Emergency Telephone No. <br /> Contractor Licence No. �Z Z:S:sl 2" <br /> Applicants Name (Print, �GL�� Title w Date �- <br /> Please check Applicable Category(1-7)and Fill in the Required Information .C"! <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) l/V•] <br /> For July 1, June 30, 19 _ _ - Disposal Sites <br /> Description(Make/Yr.,Color) <br /> SerTal No. CAL. License No. CAL.Liicn,sa Renewal No. <br /> Capacity _ __° Gal.,Weights&.Measures No. ______.•.......___ <br /> Equipment Parking Address 1 <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 a - <br /> No. of Vehicles Stored _No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST_ - - - . •• - _ _ _ _ `f <br /> R.S.-or R.C.E. Name 7_1 R.S.or R.C.E. No. T <br /> Test Location _. _--- _- T T-est Date/Time <br /> 4. ❑-SANITATION PERMIT 7, %_ - <br /> Job Address/Location �,_� <br /> Owner �� '��'- y4ddressG rr '%� 4�`✓ <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEA CFi11dG,flELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR, ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal-Se _ 4. <br /> No. of Units'-- '- Equipment Storage/Cleaning Location(s) _ <br /> 6. ❑ PACKAGE.TREAT AENT•PLANT For July 1,'-June 30,.1 i <br /> Operator Name Where Certified <br /> Planf Location ~ <br /> s f' - No. Units Served <br /> Plant Capacity� - - , <br /> 7. ❑ LAUNDRY For July 1,;June 30. 19 <br /> SIZE: ❑ Less Than.1,000 Sq._F,tt_ I]-4ore Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING;Chemicals Used/Ani-o-nt/Mo. - -- _ <br /> • I <br /> I hereby"certify that l have prepared this application and that the work will bA done in accordance.with San Joaquin County <br /> ordinances, state lav ,'and rules and regulat' ns !fMthS Joaquin Local Health District. <br /> t <br /> APPLICANT'S SIGNATURE X ---- -- ----- -- — - <br /> . E <br /> L <br /> � 1 <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> • <br /> Fee 14 Due: 1:1 ANNUALI Y ❑PER UNIT ❑ PER SITE 11 EACH [J January 1&Received By January 31 ❑ July I &Received By July 3 t <br /> i BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION! AMOUNT DUE CHECKED <br /> I DATE DATE REMITTED AMOUNT <br /> FEE � � -------- t4 <br /> LESS I t <br /> PRORATION <br /> PLUS <br /> —1—PENALLY <br /> OTHER - <br /> .OTHFR r....... - .+ ++�•. .r.~ .~ ._ ._.y -_.-.._ — « --..r•__- w_ — <br /> Received by Date Receipt No. Permit No. ' THELTON <br /> Let Mailed Deiivered - <br /> APPLICANT—RETURN ALL COPIES_ TO ENVIRONMENTAL HEALTH PERMITISERVICES 1501 EAVE.,P.O.Box 2009 STOCKTON,CA 95201' <br />