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ApplicationsWill Be Processed When Submitted Properly Completed. Be Surma a To Sign The Application. „ <br /> .�'APRZICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i rpei made o ar nous Hess in the jurisdictional area of the San Joaquin oealth Dis rict <br /> Business Nam {DBA)• d j y �� / <br /> Z Owner s' [l Address. � d <br /> a Address oyj <br /> J,Firtn Partners, Addresses and TI In Numbejs <br /> aBusiness Telephone No. ?P' 5 Ca? 6/ b <br /> _ Contractor Licence No. � <br /> Emergency elephone No. <br /> T <br /> Applicants Name {Print} Title <br /> Applicable Category Date <br /> Please check A <br /> PP g ry (1-7)and Fill in the Required Information m <br /> 1• ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) '" y <br /> For July 1, June 30, 19 - Disposal Sites <br /> Description(Make/Yr., Color) - <br /> Serial No. CAL. License No. -, <br /> Capacity `' CAL. License Renewal No. <br /> s Gal., Weights & Measures No, <br /> Equipment Parking Address i <br /> 2. ..❑ PUMPER YARD <br /> FIY 1. June'30 19 <br /> tib. k. } <br /> of Vehicles Stbred, ''- 41. "h j _ <br /> No. of Chemical Toilets Stored w 1 �. <br /> 3. ❑ PERCOLATION TEST �. <br /> R.S. or R.C.E. Name :} <br /> R.S. or R.C.E. No. <br /> Test cation Test Date/Time - f <br /> 4•SANITATION PERMITF. <br /> X�ly�Job Address/Locati ov d: : U Aa <br /> 15- <br /> Owner ' 4 I i/ mG 44- Address <br /> 'EPSEPTIC TANK OL <br /> OLEACHING FIELD SEEPAGE.PIT ❑APACKAGE PLANT <br /> �Ie7 }' <br /> ERMANENT ❑ TEMPORARY KNEW Ar <br /> ❑ 07HER F . <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 _ <br /> Type Construction � `r - � i =• ` - <br /> Disposal Site 1 <br /> a+ No. of Units Equipment Storage/Cleaning Location(s) <br /> W 5. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 T <br /> Operator Name <br /> Plant Location <br /> Where'Cgrtified <br /> Plant Capacity i No. Units Served — - - r <br /> 7. 11 � <br /> LAUNDRY For July 1, -June 30, 19 � — <br /> S1ZE: ❑ Less Than 1,000 Sq. Ft., ElMore Than 1,000 Sq. Ft. <br /> fir t <br /> ' _l! F• 1F <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> F+ <br /> I hereby certify that I have pr p;11aretl�this li ton) that the work wil!'lie done in accordancei <br /> 4 ordinances, state laws, and rte s, care tl s of e SS oaquin L al Health trict. with iSan Joaquin County <br /> APPLICANTS SIGNATURE <br /> ._FOR DEPARTMENT USE ONLY t <br /> yy---,� <br /> Fee IS DUB: El ANNUAL 1 El PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 1J July 1 &Received By July <br /> -31 <br /> BASE EXPLANATION BILLING REMITTANCE REMIT ' <br /> T DATE DATE REMITTED AMOUNT DUE CHECKED ' <br /> FEE <br /> AMOUNT <br /> LESS ' <br /> PRORATION <br /> PLUS <br /> PENALTY I ;]r�s/r Sig/! � �' // /�• -- <br /> OTHER/ - - <br /> OTHER <br /> Received by Date Receipt No. - Permit No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Issuarice Date Mail Delivered r <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />