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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 <br /> Application is hereby de to car on business in th 'urisdictional area of the an Joa uin Local Health trict <br /> H Business Name (DBA) ������_<Address � -15- 1< 25 <br /> i Owner, �� . A dress ; <br /> dC <br /> Firm Partners, Addresses and Telephone Numbers. <br /> aBusiness Telephone No. 4�-a—umss Emergency Telephone No. <br /> Contractor Licence No. 'Z <br /> LApplicants Name (Print) I�` �t Title 0�—n4 A;7z mate <br /> Please check Applicable Category (1-7j�and All 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) IM al <br /> Serial No. �M CAL. License No. CAL. License Renewal No. <br /> Capacity Gel., 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 IM <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Loc IM Test Date Time <br /> 4. R SANITATION PERMIT <br /> Job Address/L cation <br /> Owner X1!4'!6 C-S Address 1'9_2—' _7 L-S <br /> ❑ SEPTIC TANK ❑ CESSPOOL I ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY, ❑ NEW El REPAIR O <br /> 5. ❑ CHEMICAL TOILETS For JulyI1, -June 30, 19 <br /> L `-" C cry a� � <br /> Type Construction 1 Disposal Site- n <br /> No. of Units )Equipment Storage/Cleaning Location(s) <br /> 0 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location �9FY <br /> Plant Capacity I� No. Units Served <br /> r <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 have epared this application and that th work will be done in accordance with San Joaquin County <br /> ordinances, state laws, d ru nd regulatio of the San J uin Lo I Health District. <br /> APPLICANT'S SIGNATURE X <br /> a <br /> iI9iI9fI9I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑'ANNUALLY. - ❑ Pf R UNIT ❑ PER SITE ❑ EACH -❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT � <br /> k C7L? <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS �I <br /> PENALTY <br /> r <br /> OTHER IIEi 1 <br /> OTHER <br /> N l 3C4 LS - d (0 <br /> Received byDa[e IY, Receipt No. Permit No. ssua ce ate M ed Delivered - <br /> APPLICANT—RETURWALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2000 STOCKTON,CA 95201 <br />