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*, - Appllcstions Will Be Processed•When Submitted Properly Completed.Be sure io sign Inr.npp4 a•; -� i <br /> APPLICATION <br /> • iv k r►° r f" ` (For Non-Transferable,Revocable,'and Suspendable) µ. <br /> SE PTAG E <br /> A +.� ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to Carry on business in the juriisdSictional area of the San Joaquin Local Health District <br /> I Business Name 5 � $ t`��Address D' -,LA <br /> z Owner Address <br /> i � _ �� <br /> Firm Partners,Addresses and Telephone Numbers <br /> �L" Emergency Telephone No.. <br /> Business Telephone No. � ~1 <br /> Contractor Licence No.� 7 ' = � --- _ Date `" S� <br /> Applicants Name(Print) LY3N — Title <br /> od <br /> Please check Applicable Category (1-7)and Fill In the Required Information• b_. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOA EACH VEHICLE) <br /> For July 1,- June 30, 19 - -- Disposal Sites <br /> Description(Matte/Yr.,Color) CAL.License Renewal No. <br /> Serial No. CAL. License No. -- i <br /> Capacity _ Gal.,Weights&Measures No. 1 <br /> Equipment Parking Address t <br /> 2. ❑ PUMPER YARD ) � <br /> For July 1, June 30, 19 —.....— 4 <br /> No.of Vehicles Stored �,,.••` t <br /> No.of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> ��� .r •---� R.S.or R.C.E.No. t <br /> R.S.or R.C.E. Name <br /> Test Leo anon Test Date/Time.. - <br /> 4. i?SANITATION PERMIT c��.• /� ' <br /> Job Address/L ocation <br /> Owner AddressS j <br /> 11SEPTIC TANK. CESSPOOL Q�LEACHING FIELD SE PAGE IT ❑ PACKAGE PEANT 0' <br /> ©REPAIR ❑ OTHER rl <br /> CSS PERMANENT ❑ TEMPORARY ❑ NEW r si p_ <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> r is Disposal Site <br /> Type Construction i Q <br /> No.of Units _—_.. t Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT F6rJuly 1,-June 30, 19 1 Where Certified ~*t <br /> # '`•i - . <br /> Operator Name 1 + f f t <br /> e - <br /> Plant Location •-- ti { <br /> Plant Capacity No.Units Served <br /> 7. ❑ LAUNDRY For July 1.--June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq ❑ Moe Than 1,000 Sq.Ft.;Ft., <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certify that I h v prepared this ppitcation and that the'w rk 'It d done ih accordance with San Joaquin County ; <br /> ordinances,slate law , t: d re ations of <br /> 5 ri Ao 4ui Loce1`He�{h District. <br /> APPLICANT'S SIGNATURE <br /> 7• .-.-..+s... .r. _.....�-s..«r4 r �� � ,�"' _ ��(A�d r'ti"./7 7i �./�i3 <br /> y _ „ FOR DEPARTMENT USE ONLY ;�'"�,►EfS « <br /> Fee 13 OUB:❑ ANNUALLY P€R UNIT_+"1 t❑ PER SITE.. 'fl EACH [1 JenuarY t&Received 8y January 31 ❑ Jyly:J 8 Ret@lvetl 6y July 31.' <br /> 4 REMIT <br /> �w+� ., y .BILLING oy-flEM1TTANCE, -S �y,;.r'"'�AMOUsN DUE1 CHECKED <br /> BASE _ EXffiLANAlfON DATE '!� DATE ­e REMITTED t K ,. +' ` - AMOUNT }t <br /> FEE <br /> PRORATION »• +-• •^+' �'� <br /> a <br /> PLUS ... t },...•,r.�.«_.r.r �.,,, s„ t` '\'. �3 .i <br /> PENALTY <br /> ♦ 6 <br /> ..OTHER . .,.. -•- - - . <br /> OTHER��.«•.+.Y.- a.•.... ..,� +-t."'�"^`., _,. ,... ---�— <br /> ! A:. <br /> Date Receipt No. Permit No. I uance ate Mailed Detivered <br /> Received by .- tt <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.RAZELTON AVE.,P.O.Box 2009 STOC%TON,CR 95201 F <br />