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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 /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE 1. <br /> App licati is hereby made to car `on business in the risdictional area of the San Joaquin L�,cal_Health District <br />,n Business Name DBA) �'14.R Ales "3�ck 11 vt' Address /,So JSN 1 QN ii�e <br /> aOwner 1r'1 �WR�r1E' Address <br /> Firm Partners, Addresses and Telephone Numbers - <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. q3 G!I -- - <br /> L Applicants Name (Print) Title Date <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. 44 CAL, License No. CAL, Liccnse Renewal No. <br /> Capacity Gal„Weights &Measures No. <br /> Equipment Parking Address ,I <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.G.E. Name I R.S. of R.C.E. Nb: <br /> Test Location "Test Date/Time <br /> 4. 19 SANITATION PERMIT <br /> Job Address/Location 9 2 77 14LAx/ 1.2 <br /> ���'� !9Z 77 E 144 <br /> Owner LJ�= if�11C/�l�/S Address `/ -- <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD N-SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY '❑ NEW ElREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site 4Q� ��++'tP TV r1r�5 Tt^+y ��57F���j JCS�/�1 <br /> No. of Units Equipment Storage/.Cleaning Lopation(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> Where Certified - <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. FL <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo <br /> t <br /> ( <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County r <br /> ordinances, state laws, and r s and regulations of the an Joaquin Local Health District. ' <br /> APPLICANT'S SIGNATURE X - <br /> FOR DEPARTMENT USE ONLY ` <br /> Fee IS Due: ❑ ANNUALLY 0 PER UNIT ❑ PER SITE ❑ EACH ❑.January 1 &Received_By January 31 ❑ July 1 &Received.By July 31 f <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT ' <br /> FEE <br /> LESS i <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> A*,. by Gate Receipt No. _ .. - Permit No. Issuan a p' Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P-O-sox 200g STOCKTON,CA 95201 <br />