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j:_. Applications Will Be Processed When-Submitted Property Completed. Be Sure To Sign The Application.. <br /> APPLICATION <br /> F (For Non-Transferable, Revocable,and Suspendable) <br /> s ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE } <br /> Application is here4y made to car on business in the jurisdictional area of the San Joaquin Local Health District _ <br /> I F Business Name (DBA):7A/a Owner Address -� �✓ <br /> ! !�/ Jci1 ,sCZ <br /> _ -r./�� � /�-- <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No.— p <br /> I Contractor Licence No. <br /> Emergency Telephone No. <br /> LApplicants Name (Print) _ Title _ GJ".FCs _ Date 5 <br /> Please check Applicable Category (1-7) and Fill in the Required Information y <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) [���- <br /> For July 1, June 30, 19 <br /> Disposal Sites <br /> Description(Make/Yr., Color) <br />{ <br /> Serial No. I t GAL. License No. CAL. License.Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD t y <br /> For July 1, June 30, 19 ' <br /> No. of Vehicles Stored <br /> z No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C:E.146. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT = r <br /> r-� <br /> Job Address/Location <br /> Owner t .�'5 :'�' Address 2,7 <br /> Q SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE-PIT' <br /> '° 0-PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ 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) 4 <br /> 6. 11 PACKAGE TREATMENT.PLANT[�For July 1, -June 30, 19 - �_ `"7' <br /> Operator Name *" Y ` Where Certified <br /> Plant Location <br /> Plant Capacity <br /> N6.-Units Served _ } <br /> 7, ❑ LAUNDRY For July 1, -J e 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft "�Ef11P-ore Than"-1,000 Sq. Ft. - <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mol- <br /> 4 z <br /> hereby certify that I have prepared this application and that the work will be done inaccordancewith San Joaquin County <br /> ordinances, state-laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUR X <br /> f <br /> FOR DEPARTMENT USE ONLY 7iL <br /> Fee IS Due. ❑ ANNUALLY ❑ PER UNIT ❑ PFR SITE ❑ EACH ❑ January 1{ y January&Received Bar <br /> } y 31 <br /> ❑ July 1 &Received By July 31 <br /> C 33 BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE, <br /> LESS— � � <br /> PRORATION m _--.- . �• -- 4, .., —z- <br /> PLUS, Akv <br /> F PENALTY= <br /> OTHER , <br /> t � <br /> OTHER" • `g =, <br /> Received.by Datef <br /> Receipt No. .Permit No.. Issuance ate - Mailed Delivered <br /> APPLICANT`—RETURN ALL-COPIES TO: ENVIRONMENTAL HEALTH'PERMIT/SERVICES' 11601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />