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d Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> a.. T APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carryon business-in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) W, C o ,eaL/C n/ Address �S �• S �[/ l�� <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers Qll <br /> a Business Telephone No. Emergency Telephone No. 0 <br /> Contractor Licence No. <br /> Applicants Name (Print) Go Title PAP-7-AlE,-�- _ Date :3 <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 p <br /> R.S. or R.C.E. Name _ R.S. or R.C.E. No. !v I <br /> Test Location i <br /> Test Date/Time Q <br /> 4. a SANITATION PERMIT <br /> Job Address/Location a d '-� (�, 7"/NN/�lµ �2 D. /'7,o,e/ Gi4 v <br />- Owner 33u-7�y_ zow/.J Address .SAi4V_9r <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT I <br /> PERMANENT ❑ TEMPORARY ❑ NEW. REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <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 _ I <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served n <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 /> fill �Qt_� i <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 rulesandregulations of Joaquin Local Health District. t <br /> APPLICANT'S SIGNATURE X 1 Y <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 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> #_ DATE ,DATE REMITTED AMOUNT <br /> FEE <br /> r. <br /> LESS <br /> PRORATION f <br /> PLUS ` <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER - <br /> Ll <br /> Received by f Date # Receipt No. _ Permit No. Issuance Date Mailed iv <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMITISERVICES ` 1601 E.HAZELTON AVE.,,P.O.Box 2004 STOCKTON,CA 95201- <br /> ' d <br />