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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 <br /> Applicatlop_�is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health Di'b;t <br /> Business Name (DBA) cal.e / /_Cc(�C S-P-)na,'c c ��G,Address .53.3 ���` �t c ti b;/,�d,aj�_.. <br /> aOwner ulLi Ta.�L lJr'rvl rye r_S ._ Address _ C� <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. - Emergency Telephone No. <br /> Contractor Licence No. Ze 9SW <br /> L Applicants Name (Print) Title V_e4t r^rs. _ Date d"/l-IFO <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 f Disposal Sites >� <br /> Description(Make/Yr., Color) <br /> Serial No. I CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights 8 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 I <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location 1 Test Date/Time <br /> 4. ❑ SANITATION PERMIT ' <br /> Job Address/Location Jr-_ .2/901 '�irVWif-v l_� O _ �N <br /> Owner ' 7--_ Tv er s I - Address��: a/90 �w.x�. /ZO =sy4/„, J <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD 0 SEEPAGE PIT ❑ PACKAGE PLANT �t <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW J2 REPAIR ❑. OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No, of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified r <br /> Plant Location 117 <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. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> F <br /> 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, d rules an regulations of a 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 S Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE J 1 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 y 7 aLTON <br /> Received by Date Receipt No. Permit No. IMailed Delive d <br /> -APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTALHEALTH PERMIT/SERVICES 1501 E.HAZEAVE.,P.O.60x.2009 STOC TON,C 952 _ <br />