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Ap ca ions Wi}4.9�Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> JA's �� APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> 41- E SM P AVUN tMAL ENVIRONMENTAL HEALTH PERMIT <br /> DISTR CT LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) . Address__LZ • /3"' S" Si�''r �/ <br /> aOwner - Address_ -- <br /> J Firm Partners, Addresses and Telephone Numbers _. <br /> CL <br /> Business Telephone No. _ .i- s 7/ _ Emergency Telephone Na. <br /> Contractor Licence No. _ <br /> L Applicants Name (Print)__ 7=t i- ? L, GRi7 Title A160= Date <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 /> 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 <br /> 4. jd SANITATION PERMIT <br /> Job Address/Location AV/Gi 7 <br /> Owner [ C<tx Ott 7/t7aiC' _ Address — - <br /> SEPTIC TANK El CESSPOOL .QI LEACHING FIELD A SEEPAGE PIT ❑ PA6KftG�PLANT"E <br /> PERMANENT ❑ TEMPORARY JR NEW ❑ REPAIR J'� OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Loc lon(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, and rules and regulations of the Sa aquin Local Health District. <br /> APPLICANT'S SIGNATURE X — <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Dile: ❑ ANNUALLY- ' ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMfTTANGE � $ REMIT <br /> BASE EXPLANATION AMOUNTDUE CHECKED <br /> _DATE- DATE REMITTED - AMOUNT <br /> FEE - - <br /> LESS <br /> PRORATION _._ !_ ,i - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received ny Rate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P,O,Box 2009 STOCKTON,CA 95201 . <br />