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i:PP,i..u. •..•- .^„i .-� .v,.-.lu,-u • „l„ ^suv„ILrCu r- liN�,ly VV „yiv'reu. u_ ..�... .. V .a. MM✓. .u,IVi._ <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) CS3 <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE 6' <br /> Application i hereby mnade toZr 710 business in the jurisdictional area of the San caquin Local Health District <br /> usiness Name (Of fL/11-- Adores/s �7. y�7����7T <br /> Owner A , )- L( r Address lle 4 �v 2 .�f1 7P ?-/c2 /l <br /> LIrm Partners. Addresses and Telephone Numbers _ <br /> usiness Telephone No. 5�y�'S Emergency Telephone No. <br /> Contractor Licence No. <br /> r Applicants Name (Print) 4, Z, y`G'z-�-G'u� Title ZP'A���% 2-' Date — <br /> lease 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 /> LDescription(Make/Yr., Color) <br /> -erial No. CAL. License No. CAL. Lice.ae Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> equipment Parking Address <br /> PUMPER YARD <br /> or July 1, June 30, 19 <br /> _No. of Vehicles Stored <br /> Vo.of Chemical Toilets Stored <br /> L. _ <br /> ❑ PERCOLATION TEST - <br /> R.S.or R.C.E. Name R.S.or R.O.E.No. <br /> est Location Test Date/Time <br /> Lt. 0 SANITATION PERMIT // <br /> Job Address/Location 4= C- - <br /> 0 <br /> Owner ��G Address - C <br /> SEPTIC TANK CESSPOOL EACHING FIELD SEEPJaGE PIT CI PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW EPAIR 11 OTHER Q <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Lrype Construction Disposal Site <br /> '40.of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> ddant Location <br /> ant Capacity No. Units Served <br /> 7. El LAUNDRY For July 1, -June 30, 19 <br /> ` SIZE: 0 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 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 rules and re at" s of theSanJoaquin Local Health District. <br /> `APPLICANT'S SIGNATURE /�✓�' y�G <br /> LFOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑EACH ❑ January 1 A Received By January 31 ❑ July 1 E Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> 1(L BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> L out — <br /> Received by Date Receipt Na. Perms No. Issuance Date Mailed Delrvere0 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E HAZELTON AVE.,P.O.am 2009 STOCKTON,CA 95201 <br />