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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> jr Non-Transferable, Revocable, and Suspenda. -- E <br /> f ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the,jurisdictional area of the San Joaquin Local Health District.._ <br /> OF Business Name (DBA) Address <br /> z Owner 41,4V hlLO/�IIAj4r AI E! �A) `J /:'L. Address IC S. Tff��TQy� ��. A74N7`i:� <br /> Y Firm Partners, Addresses and Telephonl6 Numbers %/'y �`�Z- 1�G _ "` <br /> aBusiness Telephone No. !g— 3��� Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) �� f Title ,r� Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE, ?`! L <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 /> II i i t y: <br /> No. of Vehicles Stored + <br /> No o heroical ToiletsStored __ __ `z- <br /> 3. PERCOLATION TEST. o� f-�--- <br /> R.S. or R.C.E. Name A/ A-,-w7_Asw.l R.S. or R O.E. No. Z <br /> Test Location N' 7--feW14- 7Z'>NE Test Date/Time <br /> 4. ❑ SANITATION PERMIT <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 -; <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 /> as tobeconNo�roilsrselrNo�,w�bq-`I cerci Lhat intAe De►fomynce pt tfle worir forwhich this <br /> permit MallimIa.spt = tpermit is issued,I shall not employ any person <br /> compecows Will or eri►�orpseiipp y ryw oe.tf sa tAr fMewlq: C <br /> �y MCI=mM►OrRagrt'a� ��k+th@PWOfManceofthe work for which this'permit is issued,I shall <br /> hereby certify that 1 have pre red this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, dl s a reg ions of th San Joaquin Local Health District. <br /> S <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 REMITTANCE $ AMOUNT DUE CHECKED <br /> !!. —_. DATE :C,DATEE . REMITTED _ AMOUNT <br /> FEE b r V t� V4 T, 7 9_/ / ~7 0 /0t- 0� <br /> LESS <br /> PRORATION r <br /> PLUS <br /> PENALTY -. .. ._ <br /> OTHER <br /> i <br /> OTHER <br /> _ _.. Date Receipt tNo <br /> Received P Permit No Issuance Date Mailed Delivered ; <br /> --APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTALHEALTHPERMIT/SERVICES "'1601 E.-HAZELTCN AVE,P.O.Box 2009 STOCKTON,CA 95201-- <br /> _ i <br />