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Applications Will Be Processed When Submitted Properly Completed.Be f;ure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMI" SEPTAG,: <br /> LIQUID WASTE <br /> Application is hereby ma to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> i a Business Name(D8A)- <br /> Dw;/�( <br /> �Rl_R�4-_-- Address <br /> =Owner------�9_M.K-______ �— <br /> _. Address.__S'V'zu M�` <br /> Firm Partners,Addresses and Telephone Numbers-/VOA <br /> CL Business Telephone No. <br /> Contractor Licence No. _ —--'- -- Emergency Telephone No. <br /> --- <br /> '1 <br /> Date Applicants Name(Print)_tau•✓/ Tile <br /> �,p ----- -- <br /> -------- _QtYrY Sr4— CPL---- <br /> Please check Applicable Category(1-7)and FiiI In the Required Information <br /> �• ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1,� ._-_ June 30. 19' Disposal Sites <br /> Description(Make/Yr..Color) <br /> Serial No. _ ------------_--- G <br /> L.License No. <br /> CA <br /> ----------- <br /> --------- <br /> Capacity ;AL.License Renewal No. <br /> Gal.,Weights&Measures No. - <br /> Equipment Parkinq Address___-__-__ ----------_ <br /> 2. ❑ PUMPER YARD — --- ---------For July 1• June 30. 19 _ - - - -_--- <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets - <br /> 3. ❑ PERCOLATION TEST - <br /> ' R.S.or R.C.E.Name <br /> Test ocation -- — R.S.or R.C.E.No. <br /> d• SANITATION PERMIT -- Test Date/Time - <br /> JobAddress/Location -20`�/3- -fz/ty <br /> Owner ,P <br /> Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ;a-REPAIR EPAIR E' OTHER .DR.¢/IV <br /> S. C1 CHEMICAL TOILETS For July 1,-June 3C, 19 <br /> Type Construction4i"?41-f-'I ---- Disposal Site <br /> No.of Units _� --__ Equipment Storage/Cleaning Locationts) ---- <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30. 19 <br /> Operator Name __ __-_--_-_-_ __- - WhPre Certified <br /> -- --- <br /> ant Location _.-_-----------------------------------------------...---- a� <br /> Plant Capacity <br /> ---- --- - - -- --- _-_-_--- <br /> P Y <br /> 7. No Units Servr_d <br /> 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 /> ---------------------- ------------------ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordai �an_Jo in <br /> ordinances,state laws,a d rules and reguI o s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUREy. -- -�LCi�----.------------------------ - <br /> re cL ne _ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER Urv.T ❑ 4`ER;ITE ❑ EACI� ❑ Jaruary 1 6 Receive-)By Janumy 31 ❑July 16 Recervetl By JuIY 3' <br /> _.. —REMIT <br /> RASE EXPI ANATION BILLING REMITTANCE '— S AMOUNT DU'- CHECKED <br /> DATE j DATE I REMITTE•'• AMOUNT <br /> FEE <br /> L ESS <br /> I - - <br /> PROsATION <br /> PLUS <br /> PENAL+v <br /> OTHER <br /> OTHER <br /> Rec,:�+M by . . .. 't�vn ri,•ce01!au Pn•.na Biu Is<uance Dare M Delivered ""-.._.._. <br /> APPLICANT—RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMIT SERVICES 1601 E.HAZ£LTON AVE.,P.O.80,2009 STOCKTON,CA <br />