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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) <br /> r ENVIRONMENTAL-HIIALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is herebmade to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) A. S Al Address /Y FYI A PS77,14.f i <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �-�'- `�7� Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) J=4A;ty_z> LC�a0! Title 10,44T705-ye- Date a <br /> Please check Applicable Category (1-7) and Fill In the Required Information <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> d` f <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 4 <br /> No. of Vehicles Stored A <br /> No. of Chemical Toilets Stored t v <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name f R.S. or R.C.E. No. <br /> Test Location ( Test Date/Time I <br /> 4. 9 SANITATION PERMIT <br /> Job Address/Location 740 <br /> Owner Sly A SSar IAP 7255 � T Address 7 IS. CE73C-A? S%` Al A Al 77E Ct,4 <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑-s_'FPaGE_PIT ❑ PACKAGE PLANT <br /> Y ;' �#- <br /> ❑ PERMANENT 11 TEMPORARY 11 NEW - ❑ REPAIR OTHER A 6AA,;.D0XJ <br /> 5. ❑ CHEMICAL TOILETS For July 1, June 30, 19 � <br /> Type Construction Disposal=Site,.». '_. _ <br /> No. of Units Equipment Storage/Cleaning Location(s) I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 80, 19 #} <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity I S No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000rSq. Ft. # <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> I hereby certify that I have prepared this applica t' f nd that the work will be done in accordance with San Joaquin County <br /> Ordinances, state laws, and rules and regulations oT the n:Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE Xy <br /> FOR`DEPARTMENT USE ONLY <br /> Fee Is Due: 12 ANNUALLY El PER UNIT PER SITE —+t❑ _EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 �4 <br /> ,,y REMIT <br /> BILLING 4//REA>IITTANCE $ ' <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE'��� ' REMITTED <br /> p+� �{ AMOUNT <br /> FEE <br /> t� r <br /> LESS " <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER f <br /> OTHER <br /> r <br /> �. <br /> Received by Date Receipt No.... -Permit No. Issuan to Mailed ."ver <br /> APPLtCANTRETURN ALL TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,,P.O.Box 2009 STOC ON,CA <br />