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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION 7 9-�7� <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <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) /✓QnIELL/A!/ CO.cjS - <br /> Address PO 1-4ex /47Y4 , 47'vg;�A-M R,� <br /> aOwner ->AA� /►r1�7^!2C c�-[.y�__ Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �G G 5c7 SCS Emergency Telephone No. <br /> Contractor Licence No. / <br /> LApplicants Name (Print) k�e 14.E de_h -a-- __ Title AA'W4 � Date g i3 <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. CAL. License No. CAL. Lica.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 T <br /> 4. ffi SANITATION PERMIT <br /> Job Address/Location !7 G 7 6(14 t�6i vJTrE� �� <br /> Owner MAA�) Address es <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> +9' PERMANENT ❑ TEMPORARY ❑ NEW ❑ 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) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <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 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,,land rules and regulations of <br /> the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE.. <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,July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE LAS <br /> LESS ¢ J <br /> PRORATION <br /> PLUS d <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receiv d by ate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> A LICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTD ,CA 20 <br />