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Applications Will Be Phll-atssed When Submitted Properly Completed. Be amee To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) - 5Z <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business In the jurisdictional area of the San Joaquin Local Health District <br /> .Business Name(DBA)__ __ __ --- ---------- Address— <br /> Owner <br /> .- ----____- Address—Owner - V DLA � - --- Address YL �__-�'_• _Lib IrArJr,' - TZp• -- -- <br /> Firm Partners. Addresses and Telephone Numbers lr n _LNC • - =5 E- <br /> Business Telephone No. _� - a1'i$' t�� ---___- Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name(Print) KSsr�o.QJD T CLQ[[. -_ Title Date- <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(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 /> 3. PERCOLATION TE-ST <br /> R.S. or R.C.E. Name Eco" _ We ItA -GtJ_ R.S. or R.C.E. No <br /> Test Location__ >-s1 - Test Date/Time -_'� 7gE SUtti3 rJV LJ�� r'l gc�ni tE-,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 /> S. ❑ 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 CVEANING,Chemicals U'pedpmn <br /> I heret', certify .hat I have prepared this application and that the work will be done in accordance with San Joaquir County <br /> ordinances state laws <br /> APPLICANT'S SIGNATURE X -o4- - 1 1 )��- Title Date 1I2� <br /> = -FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY __ ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July t d Recewed By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATIONAMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> iEE Z' 7b Ill-�li�V�Y`�A — _ -7_— <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER- - I - - - --- -- -- - --- <br /> OTHiF <br /> N94131, <br /> - <br /> ec Date Receipt No Permit No issuance Date Mailed Dei�e=r•.; <br />