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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 'r Y APPLICATION <br /> -� `ron-Transferable, Revocable, and Suspendable) / <br /> r� ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicationtis hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) &J C,0XVSne ZeC-2­7en3 Address 12-X— M4 psc5 -17;?; ��✓ <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. 41 S— 5 17'71 Emergency Telephone No. <br /> Q <br /> -J Contractor Licence No,Applicants Name Name (Print) v-� + L€J�� Title aGLr1 _ Date <br /> t <br /> Please check Applicable Category(1-7) and Fill in the Required information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) V1 <br /> Far July 1, June 30, 19 Disposal Sites + <br /> Description(Make/Yr., Color) . <br /> Serial No. CAL. License No. CAL. License Renewal No. r <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. ❑ 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. L SANITATION PERMIT <br /> Job Address/Location 3 A <br /> Owner MA -L �.7`ic /.vlGE Address V!-/21D <br /> �I SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 9 SEEPAGE PIT ❑ PACKAGE PLANT <br /> t CK PERMANENT ❑ TEMPORARY JK NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ti <br /> Type Construction Disposal Site <br /> No. of Units' Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19-. <br /> ? Operator Name 1 Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> { 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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 regulatio a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - F� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER!UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> c t BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED . <br /> AMOUNT <br /> t FEE <br /> i PRORATIONPLUS <br /> } PENALTY C�� <br /> OTHER <br /> r OTHER <br /> �. Received by Date Receipt No. - Permit No Issua ce Date ailed Delivere <br /> APPLICANT—RETURN ALL COPIES TO:" ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AV .Box 2009 STOCKTON,.CA 85241 _ <br />