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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. fi <br /> -- APPLICATION <br /> }- (For Non-Transierable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT �E�TAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District > <br /> H Business Name (DBA) "D. A J°�Q,eP-1 S A4 SO Al S Address Pel $o x '�« ��'� 9�30I <br /> i Owner Address <br /> C <br /> :u-Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. Q Emergency Telephone No. <br /> a <br /> � Contractor Licence No. .2 v# 3 _ <br /> Applicants Name (Print) FLa D a p� Title — A - Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information 'V`? <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) V <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> CAL. Lic ae Renewal No. l <br /> Serial No. CAL. License No. _. l <br /> I <br /> Capacity Gal.,Weights & Measures No.' <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> I <br /> For July 1, June 30, 19 I <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. X SANITATION PERMIT <br /> Job Address/Location 7 7 'A -4A-S RC—AJCI6� C P <br /> Owner e-u1 E .4g —no A.) Address P49 QaX -411t <br /> if <br /> %SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ElTEMPORARY ❑ NEW XREPAIR 13 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 /> r ordinances, state laws, and rules and reg ations oft a Joaquin 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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ! <br /> OTHER <br /> OTHER <br /> 7 7?-7�-7 4fa7; gA+ <br /> Receivea by D to Receipt No. Permit No. Issuance Date, Mailed a Iver d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STDG 05201 <br />