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•,ti."$Iicg'ons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> t - (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEETAGE <br /> 'i <br /> !. LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business N e BA) !� �— Address ' Zt ra, OCG lWe 5'�� <br /> aOwner . Address�. <br /> is Firm Partners,Addresses andel Tel phone Numbers <br /> aBusiness Telephone No. ��_ 2© �. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> X Please check Applicable Category (1-7) and Fill in the Required Information E(pRE,`YCE'$ SEPTIC $, SEWER SERVICE <br /> F 1. © PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 co. or S(pcliiOR Catrf 95205 <br /> For July 1, June 30, 19: Disposal Sites P1-41'1-?209 <br /> Description(Make/Yr., Color) I <br /> Serial No. ;� CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address I� <br /> 2. ❑ PUMPER YARD 11 <br /> For July 1, - June 30, 191 <br /> No. of Vehicles Stored !� <br /> No,of Chemical Toilets Stored M <br /> 3. D .PERCOLATION TEST <br /> R.S. or R.C.E. Name �i R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> a <br /> 4. 1�SANITATION PERMIT <br /> Job Addresedl.,ocation <br /> r < / <br /> Owner1�07Ze'---O— Address <br /> 11SEPTIC TANK 13CESSPOOL LEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT (ft, <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW WREPAIR ❑ OTHER S <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 - it <br /> Type <br /> / <br /> Type Construction Disposal Site <br /> No. of Units h Equipment Storage/Cleaning Location(s) <br /> 6. 11 PACKAGE TREATMENT I.,PLANT For July 1, -June 30, 19 <br /> Operator Name 4*-` Where Certified +�t <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -I6une 30, 19 <br /> SIZE: ❑ Less Than 1,000 Scl. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> :i <br /> ii <br /> hereby certify that-;I <br /> hat it have prepared this application and that the work will be done in accordance wi h San aquin County <br /> ordinances, state laws, and rules and regulations of the San J aquin Local Health District.. <br /> i 'i <br /> APPLICANT'S SIGNATURE X L CI ARENGE,i <br /> 4 ei <br /> 96, ^): . Ciror 5:0.".tSl�n f3i;l. �,5 <br /> Ili FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY i� ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> I REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE LA 5 q S a _ <br /> `t ' <br /> I <br /> LESS <br /> I <br /> � PRORATION <br /> PLUS li <br /> PENALTY it - <br /> OTHER <br /> OTHER �i + <br /> y a� ato <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered v- - <br /> 01` � <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE:,P.O.Box 2009 STOCKTON,-:--.`952 - <br />