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Appiicatiorf5 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 /> Applicatio s hereby de to carry n busiryass in the jxrisdictional area of th San Joaquin Local Heal Istrict <br /> ,�Business Name (DBA) � �p ..� c iLr� Address , ._cc, i!-rz iI <br /> aOwner Address <br /> Firm Partners, Addresses and Tele h,4 Numbers <br /> E. Business Telephone No. -.'Z rod Emergency Telephone No. <br /> Contractor Licence No. I 4 <br /> L Applicants Name (Print) L E Title 4�-Z- 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 0 Disposal Sites <br /> Description(Make/Yr., Color) A <br /> Serial No. CAL. License No. CAL. Liccnse 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 �G <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. W <br /> Test ovation Test Date/Time <br /> 4, SANITATION PERMIT I <br /> Jab Address/Locat'on a4-*w-rs <br /> Owner i Address <br /> ❑ SEPTIC TANK ❑ CESSP06L LEACHING FIELD K SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW XiREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS Forlll my 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) j <br /> 6. ❑ PACKAGE TREATMENT PLANT For July.1,,-June 30, 19 } <br /> Operator Name I�I Where Certified <br /> Plant'ocation A <br /> j Plant Capacity IP I <br /> �6 No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -Juine 30, 19 , <br /> f SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - <br /> 1 <br /> - f <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an ules and r gulatio o he• oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X i <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY- ❑-PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received BY Y <br /> Jul 31 ' <br /> _ <br /> I BILLING REMITTANCE $ REMIT <br /> BASE ,II EXPLANAT N DATE - DATE REMITTED., AMOUNT DUE CHECKED <br /> !I ! AMOUNT <br /> FEE <br /> LESS —/ <br /> PRORATION <br /> PLUS JI <br /> PENALTY <br /> e <br /> OTHER G-�. �G/Y'l (� ���^CftO <br /> OTHER �� f,L •�! •. �e�` "Ilru�/Ct I <br /> O 5 C(12 Q 0 <br /> I <br /> Received by Date Ili Receipt No., Permit No. - 'I ance Pate Mailed eliv ed <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTONI AVE.,P.O.Box 2009 STO KTON, 95201 <br />