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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. * <br /> APPLICATION <br /> Y (For Non-Transferable, Revocable, and Suspendable) <br /> t <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is h reby made to car on b siness in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) +` Address_gid. I3 c <br /> — —lt� <br /> Q Owner /e �� Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �� Emergency Telephone No. <br /> C Contractor Licence No. � <br /> Applicants Name (Print) Title Oatep <br /> .t,7 <br /> Please check Applicable Category (1--7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �1 <br /> I For July 1, June 30, 19 Disposal Sites [�J <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. <br /> i Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD i <br /> For July 1, June 30, 19 <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. -❑ SANITATION PERMIT. <br /> Job Address/Location <br /> ,Own Address 01 - 5 77 <br /> SEPTIG TANKCESSPOOLACHING FIELD ❑ SEEPAGE PIT ❑' PACKAGE PLANT t <br /> ❑ PERMANENT ❑ TEMPORARY ❑_NI v z ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS Fpr_July 1, -Jurie 30;`19 <br /> Type Construction o Disposal Site t <br /> No. of Units%`'` Equipment-Storage/Cleaning Locations) ; <br /> 6. ❑ PACKAGE TREATMENT PLANT For JulyTll, - June 30, 19 a { <br /> Operator Name ' t <br /> Where Certified t <br />•' -Plant Location : <br /> Plant Capacity No. Units Served <br /> 7. Q„LAUNDRY For July 1', -June 30, 19 i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Arrl'6unt/fv1o. <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 of the San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> i * r <br /> I <br /> .4. FOR DEPARTMENT USE ONLY <br /> r <br /> Fee 1s Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE .jj EACH •❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i• BASE EXPLANATION BILLINGODATE <br /> E $ REMIT <br /> DATE REMITTEpAMOUNTDUE CHECKED <br /> AMOUNT <br /> FEEPRORATION t <br /> PLUS y <br /> PENALTY <br /> t 1. <br /> OTHER <br /> OTHER <br /> )0 7� 'S ��ZE k9a. s-�3 � <br /> Received by Date Receipt No Permit No. '15l Date Mailed Delivered <br /> - APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES+ , y-•,-�..1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> r <br /> 1 <br />