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0 Jankatry & Receiv <br />FOR DEPARTMENT USE ONLY <br />Fee Is Durk: 0 ANNUALLY 0 PER UNIT 0 PER 5115 0 EA <br />REMiTTANCE <br />DATE <br />FEE <br />LESS <br />PRORATION <br />PLUS PENALTY <br />OTHER <br />OTHER <br />BASF <br />BILLING <br />DKIE <br />:yea By <br />REMIT <br />CHECKED <br />A.MOUNT <br />i 3 a.53 <br />Rece,,ed by Dale Receipt No PerMil NO essuance Date Malted Oettverett <br />-- APPLICANT -RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 C. HAZELTON AVE„ P.O. Sox 2004 STOCKTON, CA 95201 <br />Applications Will Be Processed When Submitted Property Completed, Be Sure To Sign The Application <br />APPLICATION <br />(For Non-Transferable. Revocabie, and Suspentiable) <br />SE PIAGE ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />5ri Joaquin Local Health mulct aoo to carry on inJe jurisdictional area of <br />AO .4'4, 74 • <br /> <br />.Y4'44 Address , Business Nam BA) <br />Address _ Owner <br />Firm Partners, Addresses and Telephone NurAbers <br />t Business Telephone No. Emergency Telephone No <br />i+ Contractor Licence No. <br />Applicants Name Print) <br />Please check Applicable Category (1-7) and Fill in the Required Information <br />Date .1=42 31-4Y <br />( Tale 1424441146-1 <br />0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />For July 1, June 30, 19 Disposal Sites <br />Description (Make/Yr., Color) <br />Serial No. <br />Capacity <br />Equipment Parking Address <br />0 PUMPER YARD <br />For July 1,_ June 30, <br />No. of Vehicles Stored <br /> <br /> CAL. License No, CAL. Ltce Renewal No. <br /> <br />Gal Weights & Measures No. <br /> <br />19 <br /> <br />No. of Chemical Toilets Stored _--...• <br />0 PERCOLATION TEST <br />R.S. or ALE. Name R.S. or R.C.E. No. <br />Test_9Cation Test Date/Time <br />Job Addres i .2--ta e -" 0 viii--d Ale ..d'‘'''.1"1° <br />_ Address _/43-5/2 it isplouleer)_._ __.-X"-Ove•-• <br />; <br />__CI <br />ff SANITATION PERMIT <br />0 LEACHING FIELD GricEPAGE PIT 0 PACKAGE PLANT '-i <br />0 NEW all EPA IR 0 OTHER : <br />here Certified <br />No. Units Served <br />I hereby certify that I have prepared this application and that the <br />ordinances, state laws, and rul9tid regulations of the San Joaqui <br />APPLICANT'S SIGNATURE X — <br />ork will be done in accordance with San Joaquin County <br />cal Health District. <br /> <br />Application is hereby <br />Owner <br />0 SEPTIC TANK 0 CESSPOOL <br />')ERMANENT 0 TEMPORARY <br />3 CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Construction Disposal Site <br />No, of Units Equipment Storage/Cleaning Locat <br />0 PACKAGE TREATMENT PLANT For July 1, • June 30, 19 <br />Operator Name _., <br />Plant Location <br />Plant Capacity <br />0 LAUNDRY For July 1, - June 30, 19 <br />SIZE 0 Less Than 1,000 Sq. Ft., 0 More Than 1.000 Sq. Fti <br />O DRY CLEANING, Chemicals Used/Amount/Mo.