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1 Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> I APPLICAN- �-- <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> I ENVIRONMENTAL HEALTH PERMIT SEPTAGE '�" <br /> # LIQUID WASTE <br /> Application is ereby made to carry on business in the jurisdictional area of the Sanr�,,Joaqu'in Local Health District <br /> y Business Name (DBA) _ �Lw lam_ O <br /> z Owner Address )°:_. lam- <br /> t W a Address <br /> 2 Firm Partners, Addresses and Telephone Numbers6 .� <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) a_ J— E2iiz/ e_�K_ _Title Date <br /> r Please check Applicable Category(1-7) and Fill in the Required Information <br /> F 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) 1 <br /> Serial No, CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. i <br /> Equipment Parking Address . <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 ` <br />' No. of Vehicles Stored - <br /> No. of Chemical Toilets Stored . <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. Name <br /> I R.S. or R.C.E. No. <br /> Test Location . Test`=Date/Time <br /> 4. ❑ SANITATION PERMITT j��" 1` <br /> Job Address/Location A A'Iry=;�yC3411 <br /> Owner E - <br /> --� Address -, ^ mix/ .mow+ /� ; <br /> 0EPTIC TANK 11 CESSPOOL "LEACHING FIELD' ❑ SEEPAGEXT. ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMP.ORARY� ❑ NEW ❑ REPAIR' ❑ OTHER ` <br /> 5. 17 CHEMICAL TOILETS �For`July'l;-'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 m O <br /> Operator Name w s _ Where Certified <br /> Plant Location °' � <br /> L Plant Capacity <br /> P Y `NO. Units Served <br /> 7. ❑ LAUNDRY For July 1, -Ju4-30;19� A'. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. t �` r <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> E Ate` <br /> hereby certify that I have prepared this application and that the.work will:be done in acco dance with San Joaquin County <br /> ordinances, state laws, and rules and regulationssof the San-Joaquin Lv'cat Health-District. 1 <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY "°~ <br /> Fee IS Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ _ -REMIT <br /> �EVPP—_ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> t DATE DATE -FIEMITTED y <br /> }� [� AMOUNT # <br /> FEE s ^ } V l! <br /> LESS:___--•y,,,,,..s <br /> PRORATION� <br /> PLUS <br /> PENALTY <br /> OTHER <br /> -OTHER <br /> ip <br /> Received by Date - Receipt No. Permit No, <br /> Issuance Date Mailed Delivered - '-' <br /> APPLICANT—RETURN ALL COPIES TO' ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON-AVE.,P.O.Box 2009 STOCKTON,CA 95201 F <br />