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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. # <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGI= <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA) i4s,&)J 1C,0 Address Z AlA6�E <br /> z Owner �M Address <br /> a - <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. I�`�7� Emergency Telephone No. <br /> Contractor Licence No._,S_3 'rS>-3 _ <br /> Applicants Name (Print) 64y7zo -J � Title cam^ Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information 1 <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 �I <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 I� Test Date/Time <br /> 4. J4 SANITATION PERMIT / <br /> Job Address/Location y I r Y <br /> n f <br /> Owner _7�-b � - � <br /> Address ❑ t <br /> ❑ SEPTIC TANK 11 CESSPOOL ED LEACHING FIELD W SEEPAGE PIT PACKAGE PLANT � r <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW IV,REPAIR ❑ OTHER {� <br /> 5. ❑ CHEMICAL TOILETS For Jluly 1, -June 30, 19 <br /> Type Construction t Disposal Site <br /> No. of Units i Equipment Storage/Cleaning Location(s) Vi <br /> 8. ❑ 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, -Jurie 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ff, ❑ More Than 1,000 Sq. Ft. i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 'x-52 # <br /> .Ir <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with an Joaquin C my <br /> ordinances, state laws, and rules and regulation an Joaquin Local Health District. ' <br /> APPLICANT'S SIGNATURE X <br /> > <br /> II FOR DEPARTMENT SE LY <br /> Fee IS Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE 13 EACH January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE CS <br /> I) c <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY r` <br /> OTHER �I <br /> i <br /> OTHER <br /> Received by Date l' Receipt No. Permit No Iss ante Date Mailed Delivered <br /> APPLICANT—RETURN ALL.COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.;P-O.Box 2009STOCKTON,CA 95281 <br /> II. ' <br />