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Applications Will Be Processed When Submilted Properly Completed. Be Sure To Sign The Application. <br /> _ APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPT;, <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health Ois rict <br /> ra E ,e (DBA) r% 4,v T4e.V/ SO/Y Address 00. dO,r //O Me' P!T[- <br /> ~ el r s,0,47'(! � <br /> R s, /�y%/e.rf. Address <br /> U Firm , iers.Addresses and Telephone Numbors d <br /> IL <br /> IL Business Telephone No ✓".7- Yz/ / Emergency Telephone No <br /> Contractor Licence No. /I- <br /> Applicants <br /> FApplicants Name(Print) A r /J^,TIlo.f Title C&'ok rY"r Ter <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 D snosil Sites <br /> Description(Make/Yr.,Color) . <br /> Serial No CAL License No. CAL. L•:: !o FE c+al N3 <br /> Capacity Gal.Weights t1 Masures No <br /> e <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YArD <br /> For July 1. June 30. 19 <br /> No of Vehicles Stored - -No of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.0 E Name R.S.or R.C.E.No <br /> Test Location Tost Date/Time <br /> r <br /> 4. ❑ SANITATION PERMIT (� <br />' i l 7 .J 1.1�•A Y)-"A <br /> Job Address; <br /> Location N <br /> Owner /-/C'4- �>'o /--/= Arldrrss :2 ] S � 7 �. T •�NYY��it/ /��� i7• PON y <br /> v <br /> ® SEPTIC TANK ❑ CESSPOOL ® LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 13 PERMANENT 13 TEMPORARY El NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1.-June 30. 19 <br /> Type Construction Disposal Site t <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 /> PIAnt Location l va <br /> Plani Capaclly No Units.Served <br /> 7. ❑ LAUNDRY For July 1 -June 30 19 <br /> C,I?E ❑ Less Thnn 1,000 Sq Ft. ❑ Mr re Than 1 000 Sq Ft <br /> ❑ OF0 CLEANING Chemicals Ufed,Amount Mn <br /> I hereby certify (hal 1 have prollamrl�lhis application and thel the Work will be done In a( nco *ilh S-Tri ,loagliin County <br /> n I i n. of the San Joaquin Local Health District <br /> ordinances,stale IAWs. and ndr�a al d f qu al o ! q <br /> APPLICANT'S SIGNATURE X •/=��- <br /> CA <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due:❑ ANNtW LY ❑of n IIot U PF n sur ❑F ACH ❑Ja".Ary 1 A RKMrM BY ianuh,v 31 ❑ :uiv r A RKervM HY-1,It <br /> I REMIT <br /> BASF F%et ANAT ION Hitt ING REMITTANCE f AMOUNT DUE CHECKED <br /> tt tt MIF DATE ! REMIT' AMOUNT <br /> FEE <br /> i <br /> LESS I •\ � I( <br /> FLUS - <br /> PENALTY <br /> I \J <br /> OTHER <br /> ll <br /> / /f C� ' II •i L•' rnF.�ce((ODD�a MadM <br /> Hot e-,qd Ar 741 wn...­0 Nn 1Yrrn,(No <br /> /. <br /> If01[.NAf[l]ON AVL.. 0f•O fey 70fTOCKTON.CA <br /> — A/KICANT—a[TUIFN ALL COMET TO (NYIIIONM[NTAI HEALTH�[eMFTif[eVK[a <br />