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Applications Will Be ;sed When Submitted Properly Completed. Be To Sign The Application. <br /> APPLICATION <br /> 1 (For Non-Transferable, Revocable, and Suspendable) �_�w ZD _ 3 70`4 , Ci 1 <br /> ENVIRONMENTAL HEALTH PERMIT t l y l <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> wBusiness Name (DBA) Address <br /> �,' <br /> Owner .t-')5 ih42T'A C.1MoL__-- - -- Address ?�2�5 ----�^-ii+ TI NN�� TZ-4>' <br /> Firm Partners. Addresses and Telephone Numbers _--- JN ice- 2�Zr2_�,_ ��, N_Ca _9 <br /> Business Telephone No. _239Zo E9HH-1�ylf <br /> - --- mergency Telephone No.—__-- - --------__�.__---_ _ <br /> Contractor Licence No. <br /> Applicants Name (Print) -rsaaaQ� Title ,_ �___— Date 3�q 193 <br /> Please check Applicable Category (1-7) and FIII in the Requited Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1 June 30, 19 Disposal Sites _ <br /> Description(MakeiYr., 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 /> No of Chemical Toilets Stored. <br /> 1 X PERCOLATION TEST <br /> R S. or R C E. Name �_ IIV. P�� _ _ R.S. or R.C.E. No. <br /> Test Location -_- _r ►�= Test Date/Time t___ nC ttED JL A� <br /> 4. ❑ 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 /> 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 Locat:Gn <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/A oun li <br /> �'`'e/ <br /> �'GGOf_ �'f/tom/•is i�l�/ <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. �t G�,. <br /> APPLICANTS SIGNATURE X 1 �� -- Title `�c�F� ���— Date 3� <br /> DEPARTMENT USE ONLY <br /> Fee is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 1 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION BILLING DUE CHECKED <br /> I DATE DATE REMITTED <br /> AMOUNT <br /> FEE -- - -- - -lr � - - - �- -— <br /> LESS <br /> PRORATION <br /> PWS - �-- - <br /> PENAL TY <br /> OTHER <br /> OTHER — <br /> Received by — a e Receipt No Permit No issuance Date Mailed Delivered <br /> .�.........� ..��......... .......���... �.............�..�.. .,...•....ee.•.r.e�e...wee •.�.s u•�ei tnu•va nn n,.-enro eTnrrrnu r•oc�n• <br />