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Applications Will Be Proemsed When Submitted Properly Completed. Be SUr?lo Sign The Application. <br /> APPLICATION <br /> (For Nom-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i ereby m de to carry_gn business in the jurisdictional area of the San Joaquin Local Heal QI trlct /� <br /> N Business Name (DBA) ��/VIA �D__ __.W.t��.- �0 --- Address_��_�P������/� K--17��C4. <br /> z Owner - _ Address _ <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. Emergency Telephone No <br /> Contractor Licence No._ ___ __ - <br /> L Applicants Name (Print) -- � D lcJt-�� _-_. Title __ ____ ._ -_—_ 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 8 Measures No. <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. ❑ OLATION TMT <br /> r <br /> R.S.o C.E. me _7I ��L� (-- LI> R.S. R.C.E. No. /2` -ll�l <br /> Test Location ___ I 4 UL__[Lt��l� Q_—_ESeIk�C��Test Date/Time i_"".2-0- 0 '00 rj_l ' __ <br /> 4. ❑ SANITATION PERMIT MS TL- U 134 2` -VESTS •- WEST OF EXISTI ,, f us <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 /> No. 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. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <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 - _ vv _ Title_ __ Date _ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH_ ❑ January 1&Received By January 31 El July 1 &Received By July 31 <br /> —_---- —_ REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> ---------- --------— ---- — - - AMOUNT <br /> FEE r <br /> LESSf .D O <br /> PRORATION <br /> PLUS -- — -- - --- - --- - --- ---- -- -- ---- <br /> PENALTY - <br /> OTHER WN ^ <br /> O1HER <br /> Recewed by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> —'-- APPt(CANT-RETURN All COPIES TO: ENVIRONIAENTKI HFALTH PEnMITISERVICES -46* ' 2ELTON AVE_P.O.Boa 2009 STOCKTON,CA 85201 -- <br />