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Applications Will Be Processed When Submitted Properly Completed. Be Sue To Sign The Application. er y� <br /> APPLICAT101 r. <br /> r (For Non-Transferable, Revocable,and Suspendable) �I <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE -� <br /> LIQUID WASTE <br /> Application is hereby made to+car1111 ry on business in the jurisdictional area of tale n Joaquin Local Health District Q <br /> r y Business Name (DBA) . !<J�L;C7AEL <br /> Address-_ <br /> a Owner 04, <br /> L, 7�U "'JL - Address A 1 j~/ems i� d <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. <br /> Emergency Telephone No. <br /> Contractor Licence No. 5-S <br /> I L Applicants Name (Print) ► i Title Date <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— <br /> CAL. License No. - -- <br /> CAL. ic.:::se Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address '-2 <br /> 2. ❑ PUMPER YARD�.a.� <br /> For July 1, June 30, 9,� <br />( No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> E 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name <br /> R.S. or R.C.E. No. - `1 <br /> Test Location .r. <br /> - Test Date/Time <br /> 4. ❑ SANITATION PERMIT r i <br /> f Job Address/Location G IPn,7 <br /> y <br /> Owner A4 G S i Address •_ <br /> 6- <br /> M/SEPTIC TANK ❑ CESSPOOL LEACHING FIELD -❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENTr�`. ❑ TEMPORARY NEW �❑ REPAIR. ,: 11. OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> i Type Construction Disposal Site' <br /> r. 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 /> I Plant Capacity <br /> No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> I <br /> q . ..rn <br /> SIZE: ❑ Less Than 1,000 5q. Ft., ❑ More Than 1,000 S'-'Ff.—_ <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r ' <br /> ir <br /> 1 hereby certify that I have prepared this application and that t e work will be done in accordance with San Joaquin County f <br /> ordinances, state laws, and rules a. regu tions of tbie San Joaquin Local Health District. ,. <br /> APPLICANT'S SIGNATURE X 441 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Dile: El ANNUALLY Cl PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 �0-July 1 &Received By July 31 F .f <br /> BASE- EXPLANATION BILLING REMITTANCE $ x - REMIT <br /> DATE _ .. _ _DATE - _REMITTED AMOUNT DUE CHECKED t <br /> FEE <br /> AMOUNT <br /> � i <br /> LESS t <br /> PRORATION # a <br /> PLUS `L\ <br /> PENALTY. <br /> OTHER <br /> OTHER_ y "F <br /> -... .. -� .s . ... _ _ -T <br /> Received by Date Receipt No. Permit kc: Issuance Date T Mailed <br /> i - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Deliver d.. - <br /> -. 1601 E.HA2ELTON AVE.,.P.O.Boz 2008 STOC ON,.CAt <br />