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< .} -- - -.. .. .T -- - ..-.f k: <br /> _ <br />- Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> N ,, � .. APPLICATION r- <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> t ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE - <br /> Appl ication 's hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) f '� -' S �?✓ Address l <br /> z Owner <br /> _/ Address e4 5 <br /> J Firm Partners, Addresses and Telephone Numbers r+P li- e <br /> CL Business Telephone No. <br /> a Emergency Telephone No. 41111 <br /> Contractor Licence No. -391 c3,) 7 �../ass <br /> L Applicants Name (Print) r k Title 12 1-c fit,e s <br /> Date / -3 d- J <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 ry <br /> For July 1, - June 30, 19 Disposal Sites <br /> F <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Lic .se Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <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 Test Date/Time <br /> 4. J9 SANITATION PERMIT <br /> Job Address/Location ,2 3 - AZ <br /> Owner ry Address e9-3-33,5 o , l?o ci t <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ® SEEPAGE PIT ❑ PACKAGE PLANT l <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW VI REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) y <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 (� ! <br /> Operator Name Where Certified v� ' <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 hav 1prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an rules and re "lotions of the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> ;r <br /> FOR DEPARTMENT USE ONLY N <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE - $ <br /> DATE DATE REMITTED AMOUNT DUE CHECKED 3 <br /> AMOUNT <br /> PRORATION 2X/r�LESS ' G,/� CL i2X�lh� S,�Avj4-C <br /> PLUS r++ J 4"0 cavr Q <br /> PENALTY <br /> OTHER LvG/J-t jIf [� <br /> U V L <br /> OTHER my 13uvGr. In vw a R ! ' <br /> h41= I /14rc f Irv—Lti�rt <br /> Received by Date Receipt No. Permit-No. - ISS ante Dat .,Mailed Delivered. _ <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2004 STOCKTON,OA-95201. <br />