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Applications Will Be Processed When Submitted Properly Compleled:Be Sure To Sign The Application. <br /> APPLICATION -� <br /> (For Non-Transferable, Revocable,.and Suspendable) " n <br /> ENVIRONMENTAL HEALTH PERMIT SEI;TAGE r <br /> LIQUID WASTE TJ <br /> Applicatio Is hereby mAOe to carry on business in the jurisdictional area of the San Joaquin Local Health District _ 0 <br /> F Business Name (DBA � 176--- �� �ty�C� Address�e� <br /> aOwner M , SIL Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �r �` f �' - Emlergency Telephone No. <br /> cContractorrLicence No. I _ <br /> L AppIicant§N-a m eiP r i b t 44 Title Date /-0 �p <br /> Please check Applicable Category(1-7)and Flli in 9" <br /> Required Information ' <br /> 1. 11 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 /> E, <br /> FE ui ment Parking Address <br /> - <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.X SANITATION PERMIT �. <br /> Job Addr <br /> pip/Location <br /> Owner <br /> f/*WlE Q �rrr� Address T <br /> ❑ SEPTIC TANK ❑ CESSPOOL ; LEACHING FIELD SEEPAGE PIT ❑ PACKAGE P' fc. T <br /> VrPERMANENT ❑ TEMPORARY ❑ NEW FREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 + <br /> Type Construction E Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> .— <br /> � I r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,- June 30, 19, 4 i <br /> Operator Name ) Where Certified <br /> Plant Location I <br /> Plant Capacity 4 No. Units Served + <br /> r 7. ❑ LAUNDRY For July'1"- Lurie 30719"' "� "�*'" �y � _ „* •� ... <br /> r SIZE: ❑ Less Than 1,000 Sq. Ft., I]More Than' 1,0 SgxFt.1. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r _ t <br /> J. <br /> 4 "i <br /> I hereby certify that I have prepared this application aril tkiat the.work will:,be done in accordance with San Joaquin County <br /> ordinances, state laws, s and regulationf the San aquin Local_Health District. <br />` APPLICANT'S SIGNATURE X R - <br /> r <br /> ,b,� FOR DEPARTMENT USE ONLY •�, <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT �A1 PER SITE 1r� _Q_EACH ❑ January 1 &Received By January 3.1 ❑ July 1 &Received By July 31 N: <br /> BILLING REMITTANCE `$ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> '-..-I DATE DATE REMITTED AMOUNT <br /> FEEz/J <br /> LESS 4 <br /> PRORATION v <br /> PLUS r <br /> PENALTY � 'fiwt# <br /> OTHER � ,- <br /> i <br /> r ? <br /> OTHER i <br /> M77 <br /> 79 w� -g <br /> L - <br /> Received by Date ,. Receipt No., Permit No. Issuance Date Mailed Deliver d <br /> + APPLICANT—RETURN ALL COPIES TO' ,ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E:HAZELTON AYE.;P.O.Bo=2009 STO <br /> L ,C/15,201- <br /> - <br /> k <br />