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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ,. <br /> t APPLICATION <br /> 1 (For Non-Transferable, Revocable,and Suspendable) <br /> 11 ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of th an Jo in Local Health District <br /> y Business Name (DBA) �C`t'1(� ��0,�- tic_.__�7AWX (,0.Tate, Address 0. _a��� I.G1 1 <br /> aOwnerAddress <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. Od ' <br /> Contractor Licence No. _ <br /> CQ <br /> L PPlicants Name (Print) Title <br /> Date 1a—Please <br /> check Applicable Category (1-7)and Fill in the quired Information <br /> 1.- ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) (n <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. t CAL. Licc�se 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 f <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Loc 'on Test Date/Time <br /> 4. SANITATION PEIT +Z l <br /> Job Address/Location .7 S� ra �/�Cwt +;� � /,,ti��'�17�a�U� ,� /�/f;pr R '- ftd� <br /> Owner �' E`Iy�__ tnY�C n Address __ Q rti1 S <br /> ❑ SEPTIC TANK 0-CESSPOOL . ❑ LEACHING FIELD 2 SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHERq t l y <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30,19 <br /> Type Construction Disposal Site Cm <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> r I <br /> Operator Name Where Certified <br /> Plant Location's <br /> Plant Capacity No. Ud`its 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 /> f � <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 regplations of the San 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 /> ,BILLINGEMIT <br /> REMITTANCE $ R <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> ! DATE DATE REMITTED AMOUNT <br /> FEE <br /> �{S <br /> t <br /> LESS ` <br /> PRORATION <br /> PLUS <br /> PENALTY ; <br /> OTHER <br /> OTHER <br /> -Received by Date Receipt No: Permit No. I uance Wate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E..HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - '> <br /> 7Y, 76 OT <br />