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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r ' APPLICATION .J <br /> A <br /> (For Non-Transferable, Revocable,and Suspendable) i* <br /> SPis^G <br /> ENVIRONMENTAL HEALTH PERMIT 1 <br /> LIQUID WASTE <br /> Application is hereb made to carry on business in the jurisdictional area of the San Joaquin Local Health District O <br /> yBusiness Name (DBA) .4 /—��r�Gc. JC._ Address <br /> a Owner . <br /> 1, P�L.L -- Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> I Business Telephone No. `>y "'�+ �r Emergency Telephone No. <br /> Contractor Licence No. .a 7 5-� �i-2— r� <br /> L Applicants Name (Print) 4,4. /—u L TitleDate <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r <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 0 <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. Jc <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location � f ✓ � G'�i ��/��t' ��� �' <br /> Owner %/L1 IWA4_� Address 494{ ' v S Kc' 1 <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ 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 rules and r ulatioss of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUR <br /> FOR DEPARTMENT USE OL,Y <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Janulry.1&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING RE T ,NCE $ <br /> BASE EXPLANATION DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE J yy <br /> LESS <br /> PRORATION <br /> PLUS `` <br /> PENALTY <br /> r4f` <br /> OTHER z <br /> r <br /> OTHER <br /> �7 q- �G IS -r <br /> Received by Date Re t No. Permit No. ssuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 21109 STOCKTON,CA 95201 <br />