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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> APPLICATION <br /> !I (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE i <br /> 1 <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> E6 Business Name (DBA) �R,A AP—�21 m�+✓ Address . Ox:14 ra Sr7CAJ <br /> z Owner Address <br /> Q <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 'rte 9l°0 Emergency Telephone No. <br /> Contractor Licence No. a4s4-'� <br /> Applicants Name(Print) <br /> F 17 t�tJO 4,_V Title Al .o�^v:e Date <br /> Please check Applicable Category (1-7) and Fill in the Required information LJV <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) "C1 <br /> For July 1, June 30, 19 �I n Disposal Sites , <br /> Description(Make/Yr., Color) p <br /> Serial No. CAL. License No. CAL. License Renewal No. ] <br /> y <br /> Ca acit li Gal., Weights & Measures No. i <br /> Capacity I <br /> Equipment Parking Address <br /> 2. ❑]f LIMPER YARD II ~O <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored II <br /> No. of Chemical Toilets Stored ! <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name I R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location 23 �� Sm4tJ1.� A A r 942 <br /> ,Owner Address— AU F. RIPOAl <br /> ISG SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT 0 PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY Jff NEW m ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For'July 1,-June 30, 19 <br /> Type Construction Ij Disposal Site <br /> No. of Units Id Equipment Storage/Cleaning Location(s) <br /> 6. 0 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> f Operator Name I! Where Certified <br /> Plant Location I <br /> Plant Capacity I No, Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> i SIZE: ❑ Less Than 1,000 Sq. Ft., C1 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I . <br /> I 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 rules and regulations oft an aquin Local Health District. <br /> APPLICANT'S SIGNATURE X � <br /> !t FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY 0 PER UNIT LJ!/PER SITE ❑ EACH r ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> i ��� EXPLANATION $OA EATE <br /> G REMITTANCE $ - AMOUNT DUE CHECKED <br /> BASE <br /> REMITTED AMOUNT <br /> i <br /> FEE �J *- <br /> LESS it <br /> PRORATION <br /> i PLUS II <br /> I PENALTY <br /> } OTHER I� <br /> k <br /> OTHER <br /> -71 <br /> 'Z <br /> r Received by Date Receipt N. Permit No. Issuance Date Mailed Deli red <br /> i. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON, A 95201 <br />