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Applications Will Be essed When Submitted Properly Completed. Be'5re To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT ��' L`' ' _'I`U�2. - p. <br /> LIQUID WASTE <br /> Application is hereby made to car6 on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) SILL-`r- >�A�t Wt I jnZ Address <br /> z Owner f t(� _ Y11'-I j Address_ Le ��C -ViL.i.L• �. 1 U' �7[�1,� �1 1y1t3YU__ <br /> Firm Partners, Addresses and Telephone Numbers __ y_ q i <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) "ACr� Title fF� Date <br /> Please check Applicable Category (1-7) and Fill In the Riliquired 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 July 1, June 30, 19 <br /> No. of Vehicles Stored _ <br /> NooyChemical Toilets Stored <br /> 3. PERCOLATION TEST <br /> R.S. or R.C.E. NameTtE1N �T--� _r R.S. or R.C.E. No. Z�I L. j <br /> Test Location ' '-! Test Date/Time lb�1L-c- <br /> a. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner —.__ _- __ Address - <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction__— _ Disposal Site <br /> 0 of Units _ Equipment Storage/Cleaning Location(s) _ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 _ <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. ld Z4 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> '1A1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. <br /> APPLICANT'S SIGNATURE X Title - F� ) Date-I U <br /> f0 DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &Received By January 31 ❑ July t 3 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �j / )/ /� ----- CSG �_ - e!9 C- <br /> LESS ✓ jT C O� <br /> PRORATION -.S _ <br /> PLUS --- --------- <br /> PENALTY <br /> OTHER --- -- -- <br /> OTHERv -- <br /> Received by Date Receipt No Permd No Issuance Date Mailed Delivered _ --u• <br /> — APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PFRU1T/CFRVIrFC .m.c ...mac.:.,.. ...c .... .. ........ ..�..., .. <br />