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w. Applications Will Be Processed When Submitted Properly Completeu. tse sure Iuaryl, 1„=-er­ ; <br /> APPLICATION <br /> SE PTAGG <br /> (For Non-Transferable,Revocable;and SusQendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the 5 nn JRaquin Local 5l?C- St'cktto. I CA 9520 <br /> ' -Address <br /> m Business Name (DBA) -"Stock 'n CA 95205 r + <br /> aOwner w i F1o�1� - Pre Address <br /> Firm Partners, Addresses and Tey phone Numbers 0 1/V <br /> Emergency Telephone No, <br /> C <br /> Business Telephone No. w <br /> Contractor Licence No. "333319 "November 3 1982 <br /> Secretar /'Treasurer Date_ <br /> Ron An eline Tale <br /> LApplicants Name(Print) <br /> Please check Applicable Category (1-7) and Fill'in the Required,Informalion .. ;, ,y. ,.....UCt� Ii a-i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) —� 3 <br /> For July V- June 30,19 <br /> Disposal Sites .- .k <br /> Description(Make/Yr., CDlor) V ,- �, -CAL. License Renewal No. <br /> Serial No, CAL. License No. <br /> �. �, _. <br /> -t: <br /> Capacity Gal:;Weights &-Measures No. r <br /> Equipment Parking Address ' <br /> 2. ❑ PUMPER YARD <br /> .For July 1; June 30, 19 r <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name Test 46te/Time 3 #A <br /> !` 3 <br /> Test Location <br /> 4. 0 SANITATION PERMIT. it <br /> e `• <br /> Job Address/Location10300 WM <br /> Owner Ameron Pi6e _ Address <br /> ® SEPTIC TANK 13 CESSPOOL W LEACHING FIELD ❑ S+EEPAGE PIT ❑ PACKAGE PLANT <br /> OTHER Repla 01 <br /> ❑ PERMANENT ❑ TEMPORARY01) <br /> W NEW "REPAIR <br /> Replace Existing <br /> 5. ❑ CHEMICAL TOILETS For JUly 1,-June 30,19 -- - �-t <br /> I 1 Disposal Site y <br /> Type Construction <br /> #.,. .. ..< _.- -- -Equipment Storage/Cleaning Location(s) <br /> 1 No. of Units '- ,- <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,1-'June 30, 19 � Where Certified t = <br /> Operator,Name_ ,f <br /> Plant Location x ' <br /> 1 - No. Units-Served - <br /> Plant Capacity f <br /> 7. ❑•LAUNDRY' For July l,-June 30„19 s <br /> ❑ More Than 1,000 Sq:•Ft:; <br /> SIZE: ❑ Less Than 1,000 5q. Ft., g t <br /> ❑ DRY CLEANING,Cheny vurSIDII, <br /> micals Used/Arriount/Mo. <br /> IrF If Ih 11ntheprriormanreoritie`-vorktisr!rrhichlhl5perrnitiSisst� ,IS a no empoya <br /> I shah <br /> t Home ownerarkitanst3tlagent's Signa#urecgrtifiasthefot�lo'w Iw s 41 ay�,4;! nrk for vrliiCll this petnrif is issued,I . ,{ <br /> in such manner as to become sub' C1 to aao'kman's comm' ;;,rr 4. ric r, Ij - ;;{r <br /> e's�rtT"rtrr• r-rr'i#ir:: <�tr tnlctat.;sa aS 1 --t' i_ d'. <br /> k Contractor's hiring of sub-ccntrscting <br /> employ persons sub;ect to%vorknia1i sIt r compensation ia�,s of t aliiulnia.' <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, and rues and regulations of the San Joaquin Local Health District. a �[� 3 'r <br /> J <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 &ReceivedEB <br /> 11 REMIT 31 <br /> I7 <br /> BILLING REMITTANCE $ AMOUNT DUE. CHECKED . <br /> BASES EXPLANATION DATE 9ATE t REMITTED AMOUNT <br /> O} <br /> FEE L <br /> LESS <br /> -i <br /> PRORATION <br /> i <br /> Ptus <br /> PENALTY' <br /> OTHER <br /> OTHER a <br /> Receipt Na <br /> Permit No �g Is ance to Mailed Delivered <br /> Date - - ' r <br /> Received by r - 1601 E.HAZELTON AVE.,P.O.Box 2409 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ( <br />