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Applications Will Be Processed When Submitted Properly,Completed; Be Sur To Sign The Application. L <br /> 'APPLICATION ;L cif 33 <br /> Non-Transferable,Revocable,and,Suspendeb. •,l StPTAGE <br /> iENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> •Application is hereby made to carry D,9 business in the jurisdictional area of the Sa�aquin Local Health D'atrict <br /> w Business Name (DBA) �� Address QL of P3e�1 ��1 /1?TG/3• <br /> Owner_ T:-L./-/fL Address <br /> Firm Partners, Addresses and Telephonee-Numbars <br /> a Business Telephone No. ' 4,11'a - 'r Emergency Telephone No. �+ <br /> Contractor Licence No. I�.�;'' <br /> Applicants Name (Print) _ Gam+ Title — -`-'� Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) / <br /> r V <br /> For July 1, June 30,19'- _1 Disposal Sites <br /> Description(Make/Yr.,Ctlioij <br /> Serial No. CAL. License No. 1 CAL. License Renewal No. <br /> Capacity Gal., Weights& Measures No. T- <br /> Equipment Parking Address _ - <br /> g. ❑ PUMPER YARD For July 1, Jone 30, 19 <br /> No. of Vehicles Stored t <br /> No.. of Chemical Toilets Stored <br /> 3. PERCOLATION TEST <br /> R.S. or R.C.E..Name ' R.S.lor R.C.E. No. <br /> Test Location Test Date/Time <br /> Q.. ❑ SA ITATION PERMIT ! e• A ..'Q'a7j' 33 <br /> Job Ad ress)Location` !�/l0 0� RGG 1i�F�A� <br /> Ow 'El <br /> _ Ir <br /> SEPTIC TA_ CESSPOOL_� ' LEACHING FIELD ❑ SEEPAG� PIT. PACKAGE PLANT <br /> ❑"PERMANENT _p T€MPORARY •:> 0 NEW REPAIR I ❑ OTHER <br /> 5:. ❑ CHEMICAL TOILETS, ,Fbr July. -Ju 19 <br /> t7 <br /> Type Constructiop ` _ �` �Disposal Site <br /> No. of Units " ' Equipment Storage%beaning.Location(s)' <br /> 6. ❑ PACKAGE TREATMENT PLANT •For,Jtlly 1, -June 30,19 <br /> Operator Name - 1,....,� ""^ ° I Where Certified <br /> Plant location 4 <br /> Plant Capacity loo. Units Serbed - <br /> 7. ❑. LAUNDRY For July'1.-'June 30, 19 <br /> SIZE:. ❑.Cess Than 1,000 Sq. Ft., _ Q More Than 1,000 Sq.-R. i - O <br /> Q DRY CLEANING,Chemicals Used/Amount/Mo. <br /> 1FereFyccemty That 1-ra-ve prepyTe3-{Tris > plication and that the work will be done in accordance with San Joaquin County ' <br /> ordinances, state laws, and rules and regula ' ns a San oaquin Loaal Health District. <br /> APPLICANTS SIGNATURE X � ��� i_'•• +L <br /> r FIO"EPARTI1 f T USE ONLY ` 1 <br /> Fee Is Due: 0 ANNUALLY• ❑ PER UNIT ❑ PER SITE '1 ❑.EACHI" ❑ January1 8 Reoelyee By January 31 ❑ July 1 8 Received By July 31 <br /> 1REMIT <br /> BASE EXPLANATION ,BILLING,' REMITTANCES `f. AMOUNT DUE CHECKED <br /> ' J` •w DATE DATE REMITTED AMOUNT <br /> FEE ..J r ✓B <br /> LESS <br /> ' PRORATION <br /> PLUS <br /> PENALTYr I ' <br /> r <br /> OTHER <br /> r <br /> OTHER <br /> Receival by Date Receipt No. Permit No. 1 ante D le I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Be.;Kos STOCKTON,CA 95201 <br />