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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 SEPTAGE } <br /> LIQUID WASTE r <br /> Application is here y made to carryon business in the'urisdictional area of the San Joaquin Local Health District Cj <br /> N Business Name (DBA) /4 �1�� �1"I��`0S--_�y - Address e�it9k DM it S,y' cf SZO I <br /> aOwner Address <br /> 1 Firm Partners, Addresses and Telephone`` ��� <br /> Nuumb�51eer�rs <br /> aBusiness Telephone No. � � 7;p Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print)_ � N�-�-U �--�7 -5 Title �T Date 17--1 Q <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. t <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD A <br /> For July 1, June 30, 19 I <br /> No. of Vehicles Stored 4 <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�Locat.on Test Date/Time <br /> 4. LS SANITATION PERMIT <br /> Job Address/Lo tion "(0:7 G� . A <br /> 01 <br /> Owner n�- r�'it_—fu'tl 14A V--r- Address ���� <br /> ❑ SEPTIC TANK ❑ CESSPOOL I"L*EACHING FIELD 0-SEEPAGE PIT -r❑ PACKAGE PLANT j <br /> BO'AERMANENT ❑ TEMPORARY ❑ NEW BREPAIR ❑,OTHER k <br /> 5. ❑ CHEMICAL TOILETS For July ,,-.June 30, 19 s` <br /> Type Construction n Disposal Site <br /> No. of Units Equipment Storage/Cleariing Location(s)T7 <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. d <br /> 4 <br /> I hereby certify that I h ve prepared this application and that the work will be done in accordance with San Joaquin County y <br /> ordinances, state laws rules an regulati of th arkJoaquin Local Health District. JP� <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &ReceivedBy January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION l!/LW G 1 /W�[�C� �G!1K 1 <br /> `s + <br /> PLUS f 1 j <br /> yt <br /> PENALTY / I'( y � <br /> OTHER <br /> OTHER • <br /> Received by Date Receipt No. Permit No. "YxVI Issu ce Datb Mailed Delivered f <br /> APPLICANT 'RETURNALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 <br />