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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPT Eo <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rBusiness N ' a (DBA) tiCA �. Addr s <br /> i Owner C_ 013��rSDN_ Address V• po jC a != �1`cH. 4.o9MP 9sa 3� <br /> J Firm Partners,Addresses and Telephone Numbers <br /> !! r;-ak� )PS-2 <br /> M Business Telephone No, <br /> r'�gir• wG �a " -9 - Emergency Telephone No. o.� <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title. —.Date ��Jr <br /> - <br /> Please check Applicable Category(1-7)and Fill in the Required Information s <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. j <br /> ,F. <br /> Capacity . Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, i June 30, 19 t <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 <br /> I <br /> 4. X SANITATION PERMIT <br /> I Job Addre ' /Location -� � 6a. <br /> O�`' ner Ob a Address- / a K 19a WF_/�/4N 0/011f1� �� 't-'rC .3/ <br /> 9$EPTIC!TANK ❑. CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT -Y <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR © OTHER <br /> 5. ❑ CHEMICAL O LETS For July 11``:--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 i Where Certified <br /> Plant Location f` <br /> Plant Capacity T i No. Units Served <br /> 7. C1LAUNDRY For July 1, -June 30, 19 F ° <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ' <br /> it 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 ru s and regula ' ns th %San Joaquin Local Health District. <br /> 7-1r <br /> APPLICANTS SIGNATURE Xbs <br /> r 5 <br /> `VL/tY-fiJC... <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received ByJuly 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Ste- <br /> LESS, I - <br /> PRORATION <br /> PLUS. <br /> IFy <br /> h OTHER <br /> OTHER <br /> L,�47 4,1;06 _3 6 <br /> Received by Date I Receipt No. Permit No. - Issuance Daf Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON A .,P.O.Box 2009 STOCKTON,CA 95241 <br /> y,, <br />