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APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> 110ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquiny�Local Health Di trict <br /> L3usiness Name (DBA) A' AJ F t p /V1(, L P L� Address S I c J 'P <br /> Owner Z�l k IF -P Address <br /> Y"-irm Partners, Addresses and Telephone Numbers 12-2 g <br /> C3usiness Telephone No. Emergency Telephone No. Z{�!(S 3 <br /> ontractor Licence No. �' <br /> a <br /> I Applicants Name (Print) Title Date <br /> 'lease check Applicable Category(1-7)and Fill in the Required Information <br /> V. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) V,` <br /> For July 1, June 30, 19 Disposal Sites <br /> 3escription(Make/Yr.,Color) <br /> aerial No. CAL.License No. CAL.Licc:lse Renewal No. <br /> r <br /> Capacity Gal., Weights&Measures No. <br /> Equipment Parking Address <br /> _. ❑ PUMPER YARD ' <br /> 611ror July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> Jo:of Chemical Toilets Stored <br /> ... ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time <br /> 1. ❑ SANITATION PERMIT <br /> 01ob Address/Location 43 I-[D <br /> OwnerYvp.. Address <br /> 3 SEPTIC T NK 11 CESSPOOL LEACHING FIELD U—SEEPAGE PIT ❑ PACKAGE PLANT <br /> ..-7 PERMANENT ❑ TEMPORARY NEW [p REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 � <br /> Type Construction Disposal Site <br /> to.of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> J)perator Name Where Certified <br /> 'lant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> ;IZE: ❑ Less Than 1,000 Sq. FL, ❑ More Than 1,000 Sq. Ft. <br /> .� DRY CLEANING, Chemicals Used/Amount/Mo. AA� ! lJ --9 <br /> cf <br /> 0 if <br /> de)4+ye4/ <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, d rules and <br /> �+regulations of the San Joaquin Local Health District. <br /> ` <br /> PPLICANT'S SIGNATURE X D t CIl (LQlfA By ertrg!a7 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑PER UNIT ❑ PER SITE ❑ EACH ❑ January 1,S Receiver!By January 31 ❑ July 1 6 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Is q o 5'' <br /> LESS <br /> PRORATION 0 k— ti fJV Il.� f2. <br /> PLUS <br /> PENALTY H l� <br /> OTHER <br /> LOTHER r z <br /> 1 ✓n 3 fid:-? 1 0 (o 3 16 D-7 0 <br /> L-2ecened by ate Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPUCANT—RETURN ALL COPIES TO. ENVatONMEliTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,P.O.Sox 3009 STOCKTON,CA 95201 <br />