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Applica ne Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> �..ar Non-Transferable,-Revocable,and Su spendable) SEPTAGE <br /> Al <br /> ENVIRONMENTAL_ HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District. <br /> y Business Name (DBA) eau l'R'Iibac { Apt Z® Address 3Z W. '5 <br /> t) Liod k CQ <br /> iZ <br /> z Owner-"-M;m=a "Address "- dam <br /> 9 Firm Partners, Addresses and Telephone Numbers <br /> 0. Business Telephone No. _ 5 Emergency Telephone No. <br /> Contractor Licence No. ------------------------ <br /> Applicants Name (Print) Ter Z `' Eric Tri Please check 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 4- 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 /> t For July 1, June 30,'l 9 <br /> ' No. of Vehicles Stored _. <br /> No. of Chemical Toilets Stored <br /> 3. 19 PERCOLATION TEST - <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. _1163 A <br /> r Test Location Test Date/Time _ <br /> A �10 } f "utIQ L A . = - Jaber 88b2 <br /> 4. 1:1 SANITATION PERMITBA. <br /> Job Address/Location <br /> Owner Address g <br /> i ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 a <br /> ' Type Construction I Disposal Site <br /> No. of Units ,I Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 RECEIVED <br /> Operator Name Where Certified G <br /> Plant Location _ n inn- <br /> Plant n <br /> Capacity No. Units'Served <br /> 7. ❑ LAUNDRY For July 1, -'June 30, 19 ENVIRONMENTAL HEALTH <br /> SIZE! ❑ Less Than 1,000 Sq_. Ft., ❑ More Than 1,000 Sq.Ft. <br /> PERMIT/SERVICES <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Han+sesrnporMe+nasdeO�M'a "! twin Meperf0manCe�sl tt�ewolttfmyvt�iclothispermitisisst>�,1ShaHnotetnployanyperson <br /> ilt St1tR t119TR13r 8s to t1BE0Rte 3tlb}RCt Yttlrkfttrilt'd{;ptn} tsStltlrl ta7vi et ,0ri.rs i th3i in thapsrtorinanEe Of the+Koekfor which this permit is issued,t shall <br /> }� >�prrpKNr't Md" or a[�- M�➢ tl�tUft Game** tt� <br /> *- EttiF�-}�rsodssubla#towi>ttsman'9 c�hpe�lttoniaws ai Gtlliternis.'- <br /> I hereby certify that I have prepared this"application and that the work'wlll lie done in accordance with San Joaquin County <br /> -ordinancess'state laws, rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> A <br /> �'1!��9 <br /> v <br /> ? � <br /> r FOR DEPARTMENT USE ONLY �Ju <br /> ee Is-D ANNUALLY :;. ❑ PER UNIT ❑ PER SITE © EACH ❑ January 1 S Rece}ved By!!�y3ceived By July'37 <br /> REMIT <br /> BASE EXPLANATION .BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> EE <br /> LESS <br /> PRORATION <br /> PLUS _ <br /> PENALTY <br /> OTHER <br /> OTHER - - <br /> ^ � X57 : <br /> Received by Date 'Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES i 18o1 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 .� <br />