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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) c,EPTpC,r_ <br /> f33 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> N Business Name (DBA) i��;ii�� +C�1 ri 'G 'Z,Q Address ?Z3 '5N, ii�t rT_l fit, L�� L-fes <br /> aOwner t t I n ;3tu,,%i'��"'r Address <br /> J Firm Partners, Addresses and Telephone Numbers T1'rry P i ci Z'Z(3 50M Q <br /> a Business Telephone No. �'f a '-�'`` Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> a (t 1440 1 ka� »rri bg, ii it- 5l'[1J�`=r ` Title 31. (.. .>t . Date 'a <br /> L Applicants Name (Print) t - � � r 2� <br /> Please check Applicable Category (1-7) and Fill in the Required Information Agent <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <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 <br /> No. of Chemical Toilets Stored <br /> 3. A PERCOLATION TEST <br /> R.S. or R.C.E. Name6'Qw R.S. or R.C.E. No. <br /> Testocation 5. �12irQ1t24L�QSy�—623%E/!(r �joOlP Te�tA Date/Time <br /> 4. SANITATION PERMIT CdYl�/J� " qT 220 r/�n 893 I <br /> Job Address//,Location - <br /> Owner /1 ; ��Xi,tt�l�J/ Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER i4, ._5 - J <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 <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 /> 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, aannoi rules and regulations of the San Joaquin Local Health District. s_,c <br /> APPLICANT'S SIGNATURE X �/,4� t 4 6ly/� Y�iG it O'W'r1/74 tejjr� <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 REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 1,Cls a. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date 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 />