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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION _J <br /> Y ef" (For Non-Transferable, Revocable,and Suspendable) <br /> .�` � <br /> ENVIRONMENTAL HEALTH PERMIT SFPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District _ <br /> N Business Name (DBA) 'P, A. PA R-,*-1 /V j`S-Vx/S —Address Pct B.&X 57r'f � 9 LIZ <br /> z Owner Address <br /> a * <br /> Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. G 6– ?6 61Emergency Telephone No. <br /> d Contractor Licence No. . <br /> Applicants Name (Print) F C.BOK <br /> !� Title E 5T/��°�D`� Date L" <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 <br /> For July1��" It June 30, 19 <br /> No. of V7 J Iles Sta - <br /> th <br /> No. of Chem calll1*els.Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. K SANITATION PERMIT <br /> Job Address/Location W65 :S)w <br /> OwnerL°r Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ® PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR Pa OTHER A44,41DDnI rsEP7/G TA.�/�C <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of.Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <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 /> E ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> 3. <br /> r <br />' I hereby certify that I have prepared this?ppliYattiohll tat tlie.work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations n Jba'gJin Local Health District. <br /> APPLICANT'S SIGNATUR <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 121 ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH El January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> F DATE DATE REMITTED AMOUNT <br /> ' c <br /> Q FEE <br /> LESS <br /> PRORATION <br /> PLUS E <br /> . P, PENALTY 1'A <br /> %OTIE a <br /> A Received,by Dat'ti Receipt No Permit No. ssuance Date Mailed Delivered <br /> �t ti �- <br /> APPLICANT—RETURA'dL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo=2009 STOCKTON,CA 95201 <br />