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Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application. I <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> :fL S'23 a LIQUID WASTE 2-L( <br /> Application is hereby made to c ry on bysinjess in the jurisdictipmal area of the S n oaquin L cal Health District <br /> H Business Name (DBA) I"'led ; .SSdC/Q]'iri Address 4� �D)' Q'O Ave. <br /> a OwnerJ/1/1?es E_..____Aen , fl Addressa� 3 Lemm Ave , <br /> J Firm Partners, Addresses and Telephone Numbers 1500CL <br /> _ . 7 <br /> Business Telephone No. 9 Emergency Telephone No. 9 — 2 Z 3 7 <br /> Contractor Licence No. <br /> L Applicants Name (Print) Siv 11 oslitrx Title Aeen F Date <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. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No, <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD rfl <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. o Chemical Toilets Stored �q <br /> 3. PERCOLATION TEST MIS <br /> R.S. or� . Name �/�f G Cel w& R.S. or C No. /7 3s.9—_/ <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK Cl CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction - Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> ti. ❑ 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 /> 4 <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. <br /> APPLICANT'S SIGNATURE X Title—& Date 2__2'K' <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 /> BILLING REMITTANCE S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> ^'� �`Q tin AMOUNT <br /> FEE - � -�,- `�J• t �D l <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 2002 STOCKTON,CA 95201 <br />