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Applications Will Be Processed When Submitted Properly Completed. Be SureTo sign. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) 5):pTAGE; <br /> I' <br /> ENVIRONMENTAL HEALTH PERMIT �3 <br /> _ r30-r7 <br /> l�L$�j .,S'.r rD�-1-fL_t��-+i�-�• LIQUID WASTE �r� � 2�� 7— <br /> ' Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> An,,�g rJ .64 C_ Address_ : Tr e k " � <br /> y Business Name (DBA)1v � <br /> i a Owner �Adc <br /> �+ ' - <br /> Address d ` cr.lrjeiJ <br /> e r✓r`c. l <br /> Firm Partne , asses and Telephone Numbers <br /> aEmergency Telephone No.— <br /> a. Business Telephone No. . 7 �7�� <br /> I Contractor Licence No. <br /> r Applicants Name (Print)_ Qa hl Cy'-`� Titley��� �n�s: — Date <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 /> I Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address �p <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> kr 3. ❑ PERCOLATION TEST <br /> F R.S. or R.G.E.Name R.S. or R.G.E. No. <br /> F Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT j <br /> r W e[ <br /> Job Address/Location C - �?- ,, .� <br /> Owner ►- rw Address—_ ¢-�--�- 'r <br /> J�1 SEPTIC TANK' ❑ CESSPOOL IM LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> I ❑ PERMANENT ❑ TEMPORARY 'JO NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <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 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> I ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in ac dance with San Joaquin County <br /> ordinances, state laws nd rules and re lations of the San Joaquin Local Health District. _ <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> FFeee: ❑ ANNUALLY - ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received ByEMI <br /> eceiv dByI July 31 <br /> BASE- EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE - DATE REMITTED AMOUNT <br /> r „ c <br /> FEE % •7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by - Date Receipt No Permit No. _ Issuance Date Mailed Deliver <br /> APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK ON,C <br />