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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 /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE F <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local HqAUh District <br /> k <br /> FBusiness Name (DBA)-D4��J� �.�dtX. itX.. Address ry&�,'� .lq5-0 <br /> a Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> A. Business Telephone No. It �D7 Emergency Telephone No. <br /> Contractor Licence No. QS <br /> Applicants Name (Print) f Title Date ?ZZ d t <br /> Please check Applicable Category (1-7)and ill 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 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. El PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. LA <br /> Test Loc n Test Date/Time �) <br /> 4. SANITATION PERMIT <br /> Job Address/Location . ?✓-Sz l�Q� �+C <br /> Owner JCQ597Address <br /> EY-PERMANENT❑ SEPTIC TANK ❑ CESSPOOL ACHING FIELD �EEPAGE PIT ElPACKAGE PLANT p <br /> ❑ 13 � <br /> TEMPORARY NEW 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) R <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served ' <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 a <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. s <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> . t <br /> h <br /> I hereby certify that I ha prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws d les and re Iations o e San aq �n Local 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 I+,kanuary 31 1 ❑ July 1 &Received By July 31 �I <br /> k 'BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION DATE DAT REMITTED AMOUNT DVE CHECKED - <br /> AMOUNT <br /> FEE '�� <br /> _ r <br /> LESS <br /> PRORATION t <br /> PLUS <br /> PENALTY <br /> F <br /> OTHER <br /> i <br /> OTHER <br /> f)710X 1�l? 3 - RO <br /> Received by Date _ Receipt No Permit No. al�5�ance D to Mailed elivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Box 2009. STOCKTON,CA 95201 <br />