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AP LICA1IUN <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTI,G E <br /> SENVIRONMENTAL HEALTH PERMIT r -0-70 �,� <br /> LIQUID WASTE j <br /> 10 Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District em <br /> F Business Name (DBA) / Address <br /> I- Owner Bi SCc v Address �� �r <br /> P c B So <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) �i 15-C e <br /> 90 Title o wZ2 e/- Date S �dZ�y <br /> Please check Applicable Category(1-7)and Fill in the Required Information (/3 <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 <br /> L� �F . � r. <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 /> Test Location Test Date/Time <br /> 4. RISANITATION PERMIT <br /> Job Address/Location �v r �• 5`qr��c r a o u r—t .S T� <br /> Owner B• 5e e �s -- Address \ <br /> SEPTIC TANK ❑ CESSPOOL BLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW. ❑ REPAIR C1 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 PLANE For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity, No. Units Served <br /> T. ❑.LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ."Cl Less Than 1,000 Sq. Ft., 11 More Than 1,000 Sq. Ft. <br /> ❑ DRYICLEANING,Chemicals Used/Amount/Mo. <br /> 1 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, and rul_espnnddreregulations'of the Sa aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 4 <br /> k <br /> FOR DEPAR*MENT USE ONLY 1 <br /> Fee IS Due: ❑ ANNUALLY Q PER UNIT ❑ PER SITE ❑ EA H ❑ January 1 8 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 4---- <br /> LESS I <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> -t - - <br /> OTHER <br /> Received by ate Recei 1 No. Perm t No. Issua ce Date Kuailed pelivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 . <br />