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c Applications,011 Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> I .. APPLICATION <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 /> N Business Name (DBA). p.� is / -5rrsals Address PC 9-47K Z4�9D -57X-'Al 9972-0/ <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. - 060 Emergency Telephone No. <br /> Contractor Licence No. 5 � 3 <br /> ' Applicants Name (Print) X" D Title 4757-Ae"41V Date 9-/,�O"72 <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. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> g Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 1 <br /> 1 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> C R.S. or R.C.E. Name R.S. or R.C.E. No. �n <br /> Test Location Test Date/Time " <br /> 4. ;W SANITATION PERMIT <br /> Job Address/Location 710ra <br /> Owner Lf.�IESA� J' FE, Ate/ Address mel <br /> X SEPTIC TANK ❑ CESSPOOL LEACHING FIELD J9 SEEPAGE PIT ❑ PACKAGE PLANT TT+� <br /> IR PERMANENT ❑ TEMPORARY ❑ NEW AREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> 1 <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 C <br /> Plant Location rn <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 /> C1 I-10, k Ak.6u.VAU.U& yr., <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, and rules and regulations of the quin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> Y <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 EXPLANATIONBILLING <br /> DATE REMITTED AMOUNT DUE CHECKED - <br /> AMOUNT <br /> FEE 7 <br /> LESS <br /> PRORATION AAQ <br /> PLUS •-1 S- <br /> PENALTY <br /> OTHER <br /> OTHER <br /> kF r�t� q/1-7/ 7 -- I S' al 1'7 7 o <br /> Received by 'Date Receipt Permit No Issuance Date Mailed a ered �? ?! <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMiTlSERY10E5 - 1601 E.HAZELTON AVE.,P.O.Box 2009 ST CKTO ,CA 85 1 . <br />