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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) SES-TAGS <br /> 4'] ENVIRONMENTAL HEALTH PERMIT <br /> "" LIQUID WASTE <br /> Applications.hereb made t carry usiness in the jurisdictional area of the San <br /> Joaquin Local Health District �. <br /> / N Business Name (DRA) �Z�l�^y^� "c.i. Address ., a <br /> ` ' , { ,+ <br /> z Owner 1/�1�&a ,A oT Lzl rl Y f Address ,`l � S=Al i-n AZk A4 6-!4t.4 <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> 'la Business Telephone No. 0-7 Emergency Telephone No. <br /> Contractor Licence No. _ <br /> L Applicants Name (Print) Title 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. �J <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 Lo tion Test Date/Time <br /> 4. SANITATION PERMIT_ <br /> Address/ ocation B' i7 IA' , (4r!- X-, 47 4 <br /> Owner to ' iifdis /"'�ea f � ;t— <br /> r' , f,- Address -S-11-14 M <br /> Z SEPTIC TANK ❑ CESSPOOL RYLE CHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 6r NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site J <br /> No. of Units Equipment Storage/Cleaning Location(s) Q:-J/ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 _J <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 S n aquin C ealth District. <br /> APPL'ICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY r <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 EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE —REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION iJ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �J 47 <br /> Received by ate Receipt No. Permit Nd. Issuance Date Mailed elivere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O..Box 2009 STOCKT,bN,CA 201 <br />