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Applicatlans Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) _C <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE t <br /> LIQUID WASTE <br /> 0 <br /> i Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local H alth District pa <br /> m Business Name (OB ) b/o:e �6� I�' zAaV1C� <br /> q c? W �_ Address 4- 15+ iL''r <br /> i Owner— M i nel Ghf ll� <br /> Address /TDs :5, vii;, �li <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. Emergency Telephone No. <br /> a -N <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title �'� <br /> Date `.Aff`�y <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. SII CAL. License No. CAL. License 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 I� <br /> No. of Chemical Toilets Stored III' <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. ❑ SANITATION PERMIT I�' <br /> Job Address/Location 075_3 Hk-Y 174o)( ,/ 1V <br /> Owner �E'�' - Address /01�53 F1-&11d ' W <br /> ❑ SEPTIC TANK ❑ CESSPOEOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY (� NEW ❑ REPAIR OTHER Sll/r1p <br /> 5. 11 CHEMICAL TOILETS For.July 1, -June 30, 19 <br /> ! Type Construction Disposal Site <br /> i No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name �Pr Where Certified <br /> Plant Location <br /> Plant Capacity �I No. Units"Served <br /> 7. ❑ LAUNDRY For July 1, -Ju'ne 30, 19 '� + <br /> SIZE: El Less Than 1,000 Sq. Ft., ClMore Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> II <br /> i . <br /> , I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San_ Joaquin County v �r <br /> r ordinances, state laws, and les and,regulat, ns of the San Joaquin Local Health District. <br /> t APPLICANT'S SIGNATURE X <br /> jll FOR^DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY III❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> RASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> �f <br /> 1� <br /> LESS <br /> PRORATION 1 2/ <br /> PLUS ;Q <br /> PENALTY <br /> OTHER <br /> ! v <br /> OTHER I� 1 <br /> 77 q_I a <br /> Received by Date 0 Receipt No. - Permit No. - Issuance Date _ Mailed eliveJ d - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.Oc Box 2009 STO TON,C 95201 -I <br />