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Applications Will Be Processed When Submitted Properly Completedu'C &a Si gTll If io { <br /> APPLICATION <br /> << ; (For Non-Transferable, Revocable, and Suspendableo �r J <br /> _4 _ _ r a ENVIRONMENTAL HEALTH PERMIT V 26 4 p' <br /> LIQUID WASTE SAN -to <br /> Application is hereby made to carry on business in the jurisdictional area of the Sa( b u+A �o3ltalflmi nct rj <br /> Business Name (DBA). Address <br /> C Owner Address U , <br /> L) Firm Partners, Addresses and Telephone Numbers r <br /> a <br /> t a Business Telephone No. Emergency Telephone No. _ A q <br /> Contractor Licence No,. <br /> L Applicants Name (Print) <br /> Please check,Applicabre Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) a�nS� <br /> For July 1, June 30, 19 Disposal Sitesc�l�. r G <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 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST "Y <br /> t, R.S. or R.C.E. Name . R.S. or R.C.E. No. !V <br /> Test Location Test Date/Time <br /> x 4. W SANITATION PERMIT y <br /> Job Addr /Location / t <br /> Owner Address I tV <br /> I ?VSEPTk TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE 0ZANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 f ` <br /> Type Construction 19 '1--aeA 1i`/76s Disposal Site IQ <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19L� <br /> Operator Name W rCertified l <br /> Plant Location <br /> Plant Capacity No. Units Served �1 <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 /> I . <br /> I hereby Certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinapces, state laws, an rul and regulations of the San Jo a n Local Health District. r - <br /> APPLICANT'S SIGNATURE X LORENA L.COLSON <br /> 26837 E.Hwy. 120 <br /> Escalon,CA 95320 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due. ❑ ANNUALLY . ❑ PER UNIT PER SITE' ❑ EACH ❑ January 1 &Reteived By January 31 ❑ July_1 &Received By July 31 <br /> BILLING REMITTANCE g REMIT <br /> i BASE EXPLANATION' AMOUNTDUE CHECKED <br /> y DATE DATE REMITTED _ AMOUNT <br /> FEE `/ff � tF <br /> LESS <br /> I- PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I <br /> f OTHER <br /> r Received by Date Receipt Nb. Permit No. Issuan a Date - Mailed De d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT75ERWCES 1fio1 E.HAZELTON AYE.,P.O.BOM 2009 O N,GA 5201 <br /> - 1 <br />