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., <br /> Applications Will Be'Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 4 APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati I herb m de to carrn bisi�less in the�risdictionai area of the San J a din Loc Heal h District <br /> rn Business {DBA) I��� 1 hGH Address j . 7ro,v A� <br /> a Owner JM C AR61AE I __ Address <br /> Firm Partners, Addresses an �j honaN�,bers <br /> CL <br /> Business Telephone No. - �"�'off Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) i I Title Date. <br /> Please check Applicable Category (1-7)and Fill in the Required Information Q <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites r <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Li=p 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 <br /> 3. ❑ PERCOLATION TEST a <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. i <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMI <br /> Job Address/Location ,6V7 w nru (-M, 5, <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑-SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 11-TEMPORARY—E3-NEW "`-'� ���REPAIR -;❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ' <br /> Type Construction Disposal Site 401D /241D Gi94 ) ,_ f`f 2 74sr �t"ytc <br /> No. of Units Equipment Storage/Cleaning Locittion(s) Liw1+P <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 �_ k <br /> Operator Name `f Where Certified 1c� <br /> Plant Location is G <br /> Plant Capacity ` No. Units Served Q6 <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 9 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> hereby certify that I have prepared this application and that the work will be done in accord ce it Sa oa4 <br /> ordinances, state laws, and rules and regulations o the San Joaquin Local Health District. . , (J <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 /> 'BILLING REMITTANCE REMIT <br /> BASE ' EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE � REMITTED <br /> �}L� AMOUNT <br /> FEE <br /> LESS 1 <br /> PRORATION 11 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER I <br /> Received by DAte Receipt No. Permil.No. Issuance Date !Nailed Delivered - - <br /> APPLICANT—RETURN ALL COPIES TO: . ENVIRONMENTAL-HEALTH PERMIT/SERVICES 1601.E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br />