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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. l } <br /> APPLICATION �1 I <br /> 0� ? (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE r <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) Address <br /> a Owner l/m ON/ 0 - J_ 1,41.4 Address f q< z — AA f C <br /> Firm Partners, Addresses and Teleptlone Numbers <br /> qZ++siae s Telephone No. % Emergency Telephone No. <br /> Contractor Licence No. r <br /> L Applicants Name (Print) M OAK 12 14 461 Title k d lkl&�� 1 `p Date -k 1.21 <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. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal„ Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD I <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.C.E. Name R.S. or R.C.E. No. <br /> Testi Loc tion Test Date/Time <br /> 4. 1YSANITATION PERMIT r e/ / <br /> Job Address/Los ati n 2'1 �f `O 7 -�/ / A�� <br /> Owner -Y 1/ /no/y 2 A Address x I96x3 S 9/,pN ,dig Lf/V <br /> errr <br /> ! SEPTIC TANK E] CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT N <br /> [ PERMANENT ❑ TEMPORARY ❑ NEW 11 REPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 f <br /> Type Construction Disposal Site 5 I <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 r <br /> Operator Name Where Certified (0 <br /> Plant Location 5 <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. E <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, an sand regulations the San Jaaqui 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 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ll � -ia"7 1 r B <br /> Received by Date Receipt No. Permit No. Issua ce Date Mailed 41,v red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,A.O.Bor 2009- STO KTON,6A 95201 "� <br />