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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. - <br /> APPLICATION <br /> f`. � •f (For Non-Transferable, Revocable, and Suspendable) ; <br /> ENVIRONMENTAL HEALTH (PERMIT S�PTAGE <br /> LIQUID WASTE <br /> Application is here y made to carry on business in the jurisdictional area of th aaquin Local Health District� Q � gddrBusiness Name (DBA) 6ess <br /> 17,K ,J g42,.p1 <br /> r <br /> Z Owner i <br /> a Address <br /> a Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No, Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title __ �"�. Date_1�-ZO- ] <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, License Renewal,No. <br /> Capacity Gal., Weights & Measures No. ) <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 i <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 /> Test6La�tion Test Date/Time <br /> 4. Lel SANITATION PERMIT J <br /> Job Address/Location l�CJ13 SriCcC,) <br /> X N <br /> Owner Address.- µZa �_ z-&-4" Cg*- jo <br /> SZ�, a <br /> El SEPTIC TANK ❑ CESSPOOL LEACHING FIELDSEEPAGE PIT 11 PACKAGE PLANT t <br /> �ERMANENT C1TEMPORARY ElNEW- "` '©REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS. For July�1, -June 30, 19.1_4 <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 # f <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 ha a prepared is application a9d that the work will be done in accordance with San Joaquin County <br /> ordinances, state I rules an gulatio of th an aquin Local Health District. <br /> APPLICANT'S SIGNATUREX <br /> / yr <br /> t FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑.January 1 &Received By January 31 ❑ July 1 &Received B�Ju4 - <br /> BASE .,'EXPLANATION BILLING REMITTANCE $ _-_• MIT <br /> DATE DATE REMITTED AMOUNT-DUE CHECKED _ <br /> AMOUN <br /> FEE <br /> LESS <br /> PRORATION , R <br /> PLUS <br /> Y <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 112.1 <br /> Received by Date Receipt No. .Permit No. Iss ance ate Mailed Deliveri=d `�- <br /> APPLICANT—RREETuURNkALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> r <br />