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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEP7AGE <br /> LIQUID WASTE <br /> Applicatiis re made to arty o�usiness in the jurisdictional area of th San oaquin Local Health Distric <br /> N Business Name (DBA) VisSIS -'�1�s ��h'C. Address d <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. 60Emergency Telephone No. t <br /> Contractor Licence No. �^ <br /> Applicants Name (Print) ! Title S Date 7 d <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. Licc,se RenGwal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address Q <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 /> Teocation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Add ss/Locat' n _ <br /> Owner{ )Rd p Ki�1 _ I Address E� <br /> ❑ SEPTIC TANK CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 71 PERMANENT ❑ TEMPORARY ❑ NEW REPAIR OTHER P96/A/ $ED <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, ay rules and r gulati s tf)e Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X ' <br /> FOR 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 /> REMIT <br /> BASE EXPLANATI BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE MITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> � S� L3 o9 <br /> Received by Date Receipt No. Permit No. Ussuaibce Date Mailed ver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC ON,CA 201 <br />