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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TherApplication. <br /> . t- APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGF <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> , Business Name (DBA) �.A �rcaFc{Z�SAf �'-cS0,�15 Si.1C- Address aims: LS` M 1f~f PiR -- ' <br /> a Owner Address P. O. E a K ,fin Sik,J q6-.-k a I <br /> .Firm Partners, Addresses and Telephone Numbers P <br /> aBusiness Telephone No. !q44A —9,4077 Emergency Telephone No. <br /> Contractor Licence No. 35 (� <br /> L Applicants Name(Print) Avg I Title 5� Date 4 X57 <br /> Please check Applicable Category (1-7)and Fill in the Required Information _N%; <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. Lice^se Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> F _ <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. 1Tf <br /> Test Location Test Date/Time 1 <br /> 4. J%SANITATION PERMIT _ <br /> Job Address/Location t i a <br /> Owner 02ywItkKA Address ,-CCA &_4 �! <br /> ❑ SEPTIC TANK C3 CESSPOOL LEACHING FIELD El SEEPAGE PIT ❑ PACKAGE PLANT r�^ / <br /> ❑ PERMANENT E] TEMPORARY 11 NEW El REPAIR OTHER a� c1A ���^�CK t` <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 /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity I 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 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a les and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 1A <br /> .br FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ISI PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING ,REMITTANCE $ <br /> BASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> �s AMOUNT <br /> At <br /> FEE 11� �I s <br /> LESS , <br /> PRORATION <br /> PLUS — <br /> PENALTY ..� l� a <br /> OTHER <br /> OTHER <br /> i <br /> Received by Date j Receipt No. Permit.No, I I ssuarnce D to Mailed De' eyed 7g <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES ':�1601 E.HAZELTON AVE.,P.O.Box 2009 ST CKTON, A..101 i <br />