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r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 3 -00 APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) ` <br /> r = - -44a,-- --� NVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQU10 WASTE <br /> Applicatio hereby m de to carry on business in the jurisdictional area of the San Joa in Local ealth District <br /> y Business Name (DBA) C Address ` �"'� <br /> aOwner !M', �(I r_ , c� Address Dft�c <br /> Firm Partners, Addresses and Telephone Numbers �e-: ^ �''u=, r ! <br /> K Business Telephone No. Emergency Telephone No. � `7C7 M 5 <br /> Contractor Licence No. i <br /> 1 Cv <br /> LAppilcants Name (Print) 4.� Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) S I <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�Loo tion Test Date/Time <br /> 4. IS SANITATION PER"T j� �� ` ^ � <br /> Job Address/Location ��L .C� f!� �90-- <br /> � - / i, �, ,r �1 - 1 <br /> Owner �� _y.n gL124-? _L',, Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT (� <br /> PERMANENT ❑ TEMPORARY 1,1 NEW 0--REPAIR © OTHER V <br /> 5.- ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site R' <br /> No. of Units Equipment Storage/Cleaning Location(s). <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 <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 apphiloalian,and that the work will be done in accordance with San Joaquin County, <br /> ordinances, state laws, an rules and regulati sof hie San Joaquin Local Health District., <br /> APPLICANT'S SIGNATURE X <br /> CA <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 r <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNTDUE CHECKED <br /> DATE DATE REMITTED . <br /> AMOUNT S <br /> Li J <br /> FEE <br /> LESS ) <br /> PRORATION 4 /-6-5/ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 1. <br /> OTHER <br /> Received by Date i Receipt No. Permit No Issuance D Mailed Delivered <br /> APPLICANT—RETURN A4C COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1011 E.HAZELT .,'P.O.Bow 2009 STOCKTON,CA95 f r <br />