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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> t (For Non-Transferable, Revocable,and Suspendable) r <br /> ( Z, ! <br /> ENVIRONMENTAL HEALTH PERMIT �L`TAG <br /> LIQUID WASTE <br /> ApplicatioIs hereby de to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> w Business Name (DBA) /TD o©T4W ���'y�`CE _Address �7©� SC), ��� �1 � <br /> a Owner 6 e �C4 C17f Address /20 S; e94 <br /> Firm Partners, Addresses and Telephone hjum¢ers <br /> a. Business Telephone No. �� S— '�L((�� Emergency Telephone No. <br /> Contractor Licence No. _ <br /> L Applicants Name (Print) Title ,�ST Date 3Q � 77 <br /> Please check Applicable Category (1-7)and Fill in the Required Information 0 <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. ;9 SANITATION PERMIT <br /> Job Address/Location 4 AVM5 Q <br /> Owner_ SKA'6V+_ &fR11 Address 13ol Ale- <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> VrPERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -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 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 ruIq3.ajnd regulations of the San aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7':m7 <br /> rJm� <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed I Delive ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 S CKT N, A 95201 <br />