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+ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) _���4� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE PARc_ L ►.IOS i,2 3 <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Address <br /> Q Owner My.9,1t!,Fi-44 L. RL)S-rAIV Address -1371 W VE RNAus RoAD.T2_ AGY7_C^ 97377(o <br /> J Firm Partners, Addresses and Telephone Numbers (2s9) Z39-3121 <br /> K Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) )NAL'T1)_,R t=_. LUSZ13S Title c-N I L 1>=NG iOEM M Date A'-`Z I - JA9 <br /> Please check Applicable Category (1-7) and Fill in the Required Information 4-18 MAi-Trivw FLAzA <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) LORI, GA. 95240 <br /> For July 1, June 30, 19 Disposal Sites LZ P9) 3 L,8 — 4-%59 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored V" <br /> No. of Chemical Toilets Stored 1 <br /> 3. ❑ PERCOLATION TEST Ms-$9-41 ) PAR r-=_L kers, 1)2 3 <br /> R-S-or R.C.E. Name t-7 E R r--. CU RZJ:I S R43-vr R.C.E. No. <br /> 1 <br /> Test Location Test Date/Time T'n $V:- SCNEC'U L fc th (' <br /> 4. ❑ SANITATION PERMIT S/W Qj)AbRAW-T <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units _ Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 l., <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: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> nc- e,ma neoastobe orb ub�Ae't�r;or<ria Esc ;�ofol!o%VIn%:'dc�r(WythatIntheperformanceoftheworkforwhichthispermitIsIssued,Ishallnotemployanyperson <br /> 1- I; <br /> Contractors hiring or sub-contrarctiag egnJ=c a cartifi^r he fol;owing: I certify that iathe performance of the work for which this permit is issued,I shall <br /> employ persons subject to workman's compensalion taws of CaMoraia." <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 of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 /> REMIT <br /> BASE EXPLANATION BILLING RE TANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ( t <br /> ;6 <br /> LESS <br /> PRORATION <br /> PLUS Z <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by pare Receipt No. Permit 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 />