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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) SEf'TA.GE <br /> r rJ 1 ENVIRONMENTAL HEALTH PERMIT <br /> "L L� LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictiouaLare-q of the San Joaouin Local Health District C �U <br /> F Business Name (DBA) madres� Gt`NG'�' G� l sfrN. ZAAA✓co r�AV,*C�� <br /> a Owner Robert L BOledenave Address PO Rny 45rP French Camp. Ca �' x'/5`33(, <br /> Firm Partners, Addresses and Telephone Numbers 982 5225 <br /> IL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. / <br /> L Applicants Name (Print) Title <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. ❑ SANITATION PERMIT <br /> Job Address/Location G� <br /> Owner Same Address SAMR <br /> M SEPTIC TANK ❑ CESSPOOL K LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT op <br /> In PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER S <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 S <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 hav ep d this pplica ' n and he work will be done in accordance with San Joaquin County <br /> ordinances, state laws, LP6 I nd re Atio n JOB in Local Health District. <br /> APPLICANT'S SIGNATURE X f <br /> ems. <br /> r ,!_\tel FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January &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 �S ✓ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> / q <br /> ^'Received by I Date Receipt No. Permit No. Issuance Date Mailed Deliv ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO KTON,CA 95201 <br />