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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> k APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ell ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> a LIQUID WASTE <br /> j Applicatio reby made to carry o)=IC /46t <br /> usiness in the juris ,lctional area of the San Joaquin Loc I Health District <br /> On Business Name (DBA) � C i k pick /•4 Cie �c_& Address Q 15;-, T4 Ave <br /> aOwner —T—I#n ritR6t/&— Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> I a Business Telephone No. 6� .7 , Emergency Telephone No. I <br /> a y'7j`T al 8 <br /> � Contractor Licence No. a <br /> Applicants Name (Print) Title Date Q� <br /> Please check Applicable Category (1-7) and Fill in the Required Information (� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> r For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liczse 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 /> F Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/}�Ocation ri 17of2e^cm Cmot Rdm Tec C'� <br /> Owner L JAyP Qf A 5 Address S A Y7 r- <br /> 59 SEPTIC TANK ❑ CESSPOOL ® LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 13 NEW ® REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site 6100 1202 C�F*lf ^j)c 210 FT A-,jcq lie <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> j. 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. G <br /> A ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> F <br /> I ,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 .kflaws, an les and regulations the Sanaquin Local Health District. <br /> � J <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY 3rd PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received.By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE . <br /> LESS ` <br /> I PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ' <br /> OT 2 <br /> AA <br /> ' Received by Date Receipt Na. Permit No. Issuance Date Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICESF 1601 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 95201 _ , <br />