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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 /> rSEPT,AGE ' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE +- <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District C <br /> ,„Business Name (DBA) D A_ r?Ake K 6,,k `�E­IWS --I A IC • Address <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. `-( — <br /> �Applicants Name (Print) 7 ?11 N L-F--N �_'S.. !E;I&A—S Title ���r`t�-A P'TC Date D "�t <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 <br /> For July 1, June 30, 19 ! • r <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored T ` <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No.. <br /> Test Location Test Date/Time EYR <br /> 4. Q115ANITATION PERMIT p ; <br /> Job Address cation <br /> Owner p�— CA t.� I J-1 � 0- ,,--,,� Address � <br /> 11 SEPTIC TANK ❑ CESSPOOL BLEACHING FIELD 111-SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑'PERMANENT ❑ TEMPORARY 13 NEW ❑—R—EPAIR ❑ 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 <br /> Plant Location <br /> Plant Capacity No. Units Servedi <br /> 7. ElLAUNDRY 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. I <br /> o . <br /> 4 <br /> I hereby certify that I hav prepared this appliatCnd that th work will bedone in,Pccordance with San Joaquin County <br /> ordinances, state laws, les and gulationan Jo <br /> uiniLocal 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 ❑ Juiy 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE } $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE S <br /> LESS I <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ; <br /> (4 =� <br /> Received by Date Receipt No. Permit No. I suen a Da ail d Delivered + <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AY .Box 2809 STOCKTON,CA 95201 <br />