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Applications Will Be Pro c ed When Submitted Properly Completed. Be Sur o Sign The Application. <br /> M M <br /> APPLICATION <br /> i (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEIPTAGE <br /> 5 LIQUID WASTE <br /> { i Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) Address <br /> 'Owner Address <br /> w <br /> Firm Partners, Addresses and Telephone Numbers <br /> 6 Business Telephone No. Emergency Telephone No. <br /> -J Contractor Licence No. 4 <br /> Applicants Name (Print) VCjfA16 tl U r C_e� _._ Title 0 WAICIf Date 7- -17 <br /> - 7 <br /> -Please check Applicable Category (1-7) and Fill in the Required Information <br /> 41. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> f7.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 R Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> r ;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 /> Test Location Test Date/Time <br /> #4. ❑ SANITATION PERMLT p p <br /> Job Address/Location l .249 S 0 �16J�A. T <br /> rOwner ViFK''r,'M Uzi:alc Address .27 t✓ 7Cs !' g- �✓1 <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 13 NEW ❑ REPAIR ❑ OTHER <br /> 4 S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> I No. of Units Equipment Storage/Cleaning Location(s) oC' <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> L Plant Location p� <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 J <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. \ <br /> PI hereby certify that I have prepared this application and that the work will be done in ac orda wit n Joaquin County <br /> - ordinances, state laws, and ules;and regulations of the San Joaquin Local Health District. V�3 <br /> APPLICANT'S SIGNATURE X <br /> F a V-V <br /> C1l <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY 9-PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEESi,,,ks <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> LO <br /> Received 6y Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 85201 <br />