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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> t (For Non-Transferable, Revocable, and Suspendahle) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applieatio is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) e/ J z v,. Address T - Nc�n� <br /> a Owner <br /> Ad rEs ` ' irk,' ✓ :� <br /> J Firm Partners, Addresses and Telephone Numbers —1-75S <br /> a — / r7�y Emergency Tele hone No. 7 `a <br /> a. Business Telephone No. 9 y P <br /> a � <br /> � Contractor Licence No. :39i3 '7_ I <br /> L Applicants Name (Print) i G �` Title ��.�N�r -- Date �'-/ �� - Cn <br /> Please check Applicable Category (1-7)and FIII in the Req fired Information W <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTIRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 { Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No, CAL. Liccnse Renewal No. <br /> r <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 e <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. UI <br /> Test Location Test Date/Time <br /> 4 <br /> 4. ❑ SANITATION PERMIT ` 4,, U' i <br /> Job Address/Location 3 / U�v /� GC�F� /02� _S C'�9��►'j <br /> Owner dcimss <br /> 9 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PAC AGE PLAINT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER A <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) 1 <br /> 5. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 \ <br /> Operator Name 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. 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 /> ordinances, state laws, d rules an regulations of the San Joaquin Local Health District.. <br /> APPLICANT'S SIGNATURE X — <br /> Ad <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH C January 1 &Received By January 31 ❑ July 1 &Received By JUIy 31 <br /> REMIT , <br /> BASEEXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 4 .. DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION l <br /> PLUS " I <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No. I suance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> ' . . I <br />