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Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) S'r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl icattoW herprby made to arty n busine In the j risd' ti l area of the S Joa:2 Jin Local Health Distri <br /> „ Business Name( ) CGs a.+ r<� ` l�dress 76i�- <br /> Owner -. _ ( t-a�� f <br /> ._.. - _ <br /> U \G �1.�Address <br /> Firm Partners,Addresses an Telephone Numbers <br /> iBusiness Telephone No ,r�f•S..j O_S Emergency Telephone No. <br /> Contractor Licence No. ..�.P. 7 Z. �• --- -_- --------- - - - - -- —+_= — -- <br /> Applicants Name(Print) n 4--4-k-R._Letk_� V- P _ Title _ 5ecl rr-r es._._.-.._ Date <br /> Please check Applicable Category(1-7)and Fill In the Required Information t� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For Julv 1, -_ . June 30. 19 - _ Disposal Sites <br /> Description(MI le/'yr Color) -__ --.------__---� <br /> Serial No. __ -. CAL.License No. _ _ _—_-.-_CAL.Lie --a Renewal No. <br /> Capacity ,_-_-________ Gat.,Weights&Measures No. _ <br /> Equipment Parlr•ne Address. _- <br /> 2. ❑ pUMPEF YARDFor July 1,__-- June 30, 19 _ <br /> No.of Vehicles Stored <br /> No of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ` <br /> R.S.or R.C.E.Name <br /> Test Location TestDate/Time.._ <br /> a. C3SANITATION PERMIT ^ <br /> Job Address/Loc9tion <br /> ' - 2 - <br /> Owner_�L.�7-1•J..IG._.._ Address I-ea�.a y y -'`- 'SI-S- -- <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD MA F.IFPAO .PIT ❑ PACKAGE WANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW Q�►;�^A.IR O OTHER <br /> s. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction - u,sposal Site•._ <br /> No of units .. _ _ Equipment <br /> Storage/Cleaninq Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT for July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Ptant Capacity -- - - No Units Served <br /> T. ❑ LAUNDRY For July 1,-June 30, 19 . . <br /> SIZE. ❑ Less Than 1.000 Sq FI., ❑ More Than 1,000 Sq.Ft <br /> ❑ DRY CLEANING,Chemicals Used/Amount,'Mo. _.__.__ <br /> WewwwaweEaeswwepwt's eertlMaeMfbaewftq-.A-* t1V!%r'h"��r!TZLslteo!!MwNtNo►whkhlahttrsrnMhfsslNr.IsMllnotM►DbyatM/s►soA" . 4 <br /> N swh manner as 10 become subigo to workman$ronlxnseilur 41e110t Calllerra <br /> Ce+wwtw*a hkkq eE "o-cotwrretirla 1111/I wv earwie5 "Kin telleakw. I C«lits that is the perfomlaaoe at ft work lot tsftich this pr"Is issued.I sltaN -fl <br /> emeloy 1»►sons sugeet to workman s oo1TIFellsa ion laws of CdIdolrns' <br /> 1 hereby certlfv ;hat I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinin: atste laws,and rulesAnd regulations of the`S4wJt7 n Local Health Distnc <br /> APPLICANT'S SIGNATURE X '^ Qi>7.7C'� / •r� - _� C/� .s�-r[�-' <br /> FOR DEPARTMENT USE ONLY <br /> Fee It Due: D ANNUALLY ❑PER UNIT ❑ PER silt ❑f A(-..H ❑ January 1 a R+luoverl By January 71 D Jury 1 6 Rece.v4-A By July 71 <br /> REMIT <br /> fl A'Ir IF■PL ANAiION RILL IN(', REMITTANCE f AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> rEE t f4 \ t = <br /> lEss r _ 1 ✓ <br /> PRONATION <br /> PLUS <br /> PENAL IV <br /> OTHER <br /> a. <br /> N" n. <br /> R,•r,-.nit• Ilnr r, <br /> 11 �.�r Nn u Is anala Maned Dar,vnr.y <br /> L_. <br /> APPLICANTRETURNALL COPV6 TO rNVIRONMEN TAL HEALTH PERMIT Se RVICES 1901 1 HASELTON AVE.,P sen e00e STOCKTON.CA eS?p1--- <br />