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mll-mTT.n-TO 8111DCrrvicessea nrnen buomITTeaPropertyt;omple>tea. tse tsure t o algn t ne %ppircation. <br /> APPLICATION <br /> ° (�or Non-Transferable, Revocable,and Suspenda"0M) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby madg4o carry on-business in the jurisdictional area of the San Joaquin Loca .Health is , <br /> [Business Name AD11IVUPJ Address 6 <br /> aOwner—�>��—_ ' r✓ _. Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. ZK 4- f-'(- " Emergency Telephone No. <br /> Contractor Licence No. <br /> c Applicants Name (Print) e C 1 Title ^4 Date 2- 1./fz7 �Cf <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal. Sites <br /> is 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 /> 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 /> Test Location Test Date/Time <br /> k 4. 11 SANITATION PERMIT <br /> Job Address/Location <br /> Owner �� G Address <br /> W��, SS TIC TANK CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> —` u�'PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER V <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> ` Type Construction Disposal Site <br /> r 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. 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, and rTlpygd regulatio of 4he SJoaquin Local Health District. <br /> �. <br /> APPLICANT'S SIGNATURE <br /> AW <br /> r <br /> j � <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH - 0 January 1 &Received By January 31 ❑.July 1 8 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> f AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> r LESS <br /> PRORATION <br /> PLUS <br /> PENALTY y <br /> i^ OTHER 1 <br /> OTHER <br /> Received by - Date Receipt No. Permit No. Issuance to r Mailed Deliveretl <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.B x009 2STOCKTON,ZA 95201 <br /> r,p� . <br />