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To gllua .... <br /> -�• <br /> Applications Will.Be Processed When Submitted Properly CompleteBeSure <br /> APPLICATION . <br /> (For Non-'Transferable, Revocable,and Suspendable) gpI,AGE <br /> ENVIRONMENTAL HEALTH PERMIT 6- <br /> LIQUID WASTE :J <br /> ict <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Loi 1aHeeal�hD`SLane <br /> C Address y <br /> y Business Name (DBA) <br /> Address <br /> a Owner--l—a—MCDOMAId— <br /> I Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. 9 i7_- 0,1 <br /> 97 <br /> aBusiness Telephone No. k <br />_J Contractor Licence No. Title 'y''F'r Date <br /> i <br /> L Applicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill In the Required Intormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) S <br /> For July 1, �-,*_, 30, 19 -i Disposal Sites <br /> Description(Make/Yr", Color) M - " <br /> CRL. License Na. -CAL. License Renewal No. V <br /> Serial No. � <br /> Gal.,Weights &Measures No. A, <br /> Capacity <br /> Equipment Parking Address <br /> 2' ❑ PUMPER YARD `'I <br /> > June 30, 19 <br /> For July 1, _I <br /> No. of Vehicles Shored _. <br /> No. of ChemicalVToilets Stored <br /> 3. ❑ PERCOLATION TEST k <br /> R.S.or R.C.E. No. <br /> R.S. or R.G.E. Name <br /> Test Date/Time _ <br /> Test Location <br /> 4. El SANITATION PERMIT �� `` e j <br /> tt <br /> Job Address/Location Address <br /> Owner13 I. ElPACKAGE PLANT e <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ OTHER <br /> PERMANEN <br /> T ❑ TEMPORARY NEW ❑ REPAIR <br /> CHEMICAL TOILETS For July 1, - June 30, 19 <br /> Dis osal,Site <br /> Type Construction , p + <br /> No. of Units t.- E ulpment,Storage/Gleaning Location(s) g*� # R f <br /> ., ql June 30. 19' t -.g t 1t.' t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - " Where Certified L <br /> Operator Name <br /> y Plant Location <br /> No. Units Served Zt <br /> Plant Capacity <br /> 7. 11LAUNDRY For July 1, -June 30, 19 ` f <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. r�t' <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certify <br /> that l have prepared this applic tion and that the work will be done in.accord nce with San Joaq"uln County <br /> ordinances, state laws, and rules"and r gulatio o the San Joaqui Loc ealth Dista't. TMt <br /> L APPLICANT'S SIGNATURE X r <br /> ; yII i4 3 ;$YOR•DEPAR-rMENT USE ONLY <br /> ANNUALLY 3 <br /> REMIT <br /> 31 <br /> Fee IS Due:' " ❑ ❑ PER UNIT ❑ PER SITE 0 EACH � ❑ January 1 &Received By January131 ❑ July 1 &Received By Ju1Y <br /> 81CLI G REMITT CE AMOUNT DUE CHECKED <br /> - BASE EXPLANATION �,. DATE': REMITTED AMOUNT <br /> / J r <br /> FEE <br /> [ LESS <br /> k PRORATION . <br /> PLUS S <br /> I PENALTY <br /> OTHER <br /> k <br /> OTHER <br /> { <br /> Received ey i.-- Date Receipt No. <br /> Permit Na. Issuance Date Mailed Delivered <br /> STL�'E T PERMIT/SERVICESE 16r E: �LTON AVE.,P.O.aox 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIESTO: ENyIRONMEITA <br />