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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. t <br /> APPLICATION r <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District/l <br /> w Business Name (DBA) �r.4, Address 13i! 1!�/9 &TG A <br /> aOwner /t , f4,� E,/_!_cr Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No, g tj� _Q Er Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print.) -_ A ., rc!4, Title ����— _.-- Date 021ep 1 <br /> Please check Applicable Category (1-7)and Fill 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. ❑ 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 L6 J `Q — <br /> Job Address/Location <br /> Owner G-r /YldS% Address r <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 0-TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> � �v <br /> Type Construction ':' Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,,1 ._ p <br /> Operator Name Where Certified r <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. J <br /> - y W <br /> 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 r ulati ns of the San Joaquin 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 8y January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> ` BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS ' <br /> PENALTY <br /> OTHER - <br /> OTHER <br /> /6763 <br /> Received by Date Receipt No. Permit No. puanCq Dalel Mail Delivered .41 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />