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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> • i APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable)C) / <br /> SEPT�E <br /> ENVIRONMENTAL HEALTH PERMIT � <br /> LIQUID WASTE <br /> Application is hereby made to carry onj2usiness in the jurisdictional area of the San Joaquin Local Health District <br /> ,,;Business Name (DBA) VA PARA-1SW ; <zos>sXioc- Address,"n gnu 1'-S6• Q sZ©1 <br /> i Owner Address <br /> C <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. �f�1P s 7 `®� Emergency Telephone No. <br /> Contractor Licence No. - , <br /> L Applicants Name (Print) 5ixis Title A/l)A..-•9-ie Date _ �--- <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) p� <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No, t;At.aLicense Ron al No. <br /> Capacity Gal.,Weights &Measures No, 4 <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> T st ocation Test Date/Time <br /> 4. SANITATION PERMIT "- <br /> Job Addre s/Locatio <br /> Owner Address Z <br /> ❑ SEPTIC TANK ❑ CESSPOOLAM-LEACHING FIELD XSEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEWREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipe etlt Storagle/CJeariing Loca4tion(s) '. <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 rt <br /> Operator Name Where Certified ' <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 /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. Ish-aIR'Hoole owner orlicensrl 'Zr`2. p 'fir ,ti—fn L?h!i�1� cert YR° 1 '1 then ;1 S'r11?r_,^"'1"I�#p rnlr.for4 Mich lh (�,I'?[,t4rr:ploy ifl SC1Ch fllatlner 3 tC 3tt_i l �( i OF W rContractor5 hre�r� or rr� 1 r , a ri&G3 le foiiovvMg: 1 CStNy that I t it perfor. Jli e�f#lie NJC,K leriv,ZtC,i this pe�:pit iyls_a eti,i <br /> employ persons subject to v,,,Ahaepared <br /> 4 w,t:aVtiS Gt Gailfoflila." <br /> I hereby certify thathis application and that the work will be done in accgr' ace with'kSa n Countyordinances, state laulat' of th JoaWioDistr' vV'', `APPLICANT'S SIGNATURE X <br /> . 1 `'- <br /> F6kbkPARTNENT USE ONLY <br /> Fee 1$Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH, ❑ January 1 &Received By January 31 ❑ July 1 &Reef.ilked By July,31 <br /> -t*REM IT.`y <br /> BASE EXPLANATION : BILLING REMITTANCE $ ,�t - AMO*T DUE CHECKED <br /> _DATE DATE RENGTTED AMOUNT j <br /> FEE <br /> LESS r <br /> PRORATION <br /> PLUS - .. <br /> PENALTY <br /> OTHER 'a i <br /> OTHER is <br /> Received by Date Receipt No. Permit NQ. Issuance Date MaileG Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVkCES1601 E.HAZELTON'AVE.,P.O.aox 2009 STOCKTON,CA 95�1 <br />