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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign,The Application. i <br /> m. <br /> p APPLICATION .4 <br /> a� <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> s ENVIRONMENTAL HEALW PERMITTk <br /> LIQUID WASTE <br /> Application is hereby made to cafry on business in the jurisdictional area of the San Joaquin Local'Health District <br /> OF Business Name (DBA) P, R 91S Z _,Address 'QSPYLJ!!� ©T, <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> EL Business Telephone No.. L4&(,,,t-961O-7 - Emergency Telephone No. <br /> Contractor Licence No. <br /> Val <br /> L Applicants Name (Print) z Title Dates y <br /> Please check Applicable Category(1-7)and Fill In the Required Information . <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. - 'rCAL`Licetlse No. :J, J- — CAL:-License-Renewal <br /> N04- <br /> Capacity ; Gal., Weights &Measures No. <br /> Equipment Parking Address E <br /> 2. PUMPER.'YAiRD "a. '"' <br /> For July 1," June 30, 19 <br /> No. of Vehicles..Stored ` <br /> No. 06 Chemical-Toilets Stored u <br /> 3. ❑ PERCOLATION"TEST <br /> r <br /> R.S. or R.C.E. Name. ,jsw R.S. R.C.E. o. r�:¢�_ '-. - .., � - <br /> Test�wLooc tion M~�T -Nest D .S.ate/Time . filKms" r „ '1 p 1 <br /> 4. I1 SANITATION PERMIT s X1047-J 7C " <br /> Job Address/Location SZS� Imo? - 1 <br /> Owner 'T Address <br /> U.-tfPTIC TANK ❑ CESSPOOL`` �". M] &I CHING FIsELD-'U'TEEPAGE PIT ❑ PACKAGE PLANT f" 4 <br /> ❑ REPAIR ❑ OTHER ' <br /> I�P�RMANENT ❑ TEMPORARY D W `U."5 ' <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 y <br /> Operator Name x Wlej tr�Certified r <br /> M'- ^s,. _ - <br /> Plant Location >+ t p -*� �, .r qz` }- <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July'l, -June 30, 19 - f" <br /> i" <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,l ❑ More Than 1,000 Sq. Ft. 'r _ f <br /> i ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ` x ' . <br /> I herefy`certify that;I prepared this application tha the wor will be done in accordance with San Joaquin County <br /> ordinan ec s, state taws, es and r ations of an Jo Loc I Health District. t t <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY.....,... <br /> E ' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> - ` I BILLING REMITTANCE $ REMIT <br /> t BASE 1 EXPLANATION AMOUNT DUE CHECKED <br /> (: DATE DATE REMITTED 1 ' AMOUNT <br /> FEE n <br /> LESS <br /> K PRORATION r <br /> PLUS °✓ l <br /> PENALTY - <br /> E <br /> OTHER <br /> OTHER+, -Z—Iter «•..,, <br /> -- Received by Date Heceipt No. Permit No. JJt.Issuance Date Mailed, Delivered <br /> - <br /> A 95201 <br /> APPLICANT—RETURN ALL COPIES TO:. E 60 <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES X11 E.HAZELTON AVE.,P.O.Box 009_ �STOCKTON,C . <br />