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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> E - (For Non-Transferable, Revocable, and Suspendable) <br /> p ENVIRONMENTAL HEALTH PERMIT SEATAGE <br /> LIQUID WASTE C1 <br /> Application is hereby-made toe on business in the jurisdictional area oft San Joaquin LocaaA j-j Ith District ���,j <br /> w Business ame (DBA} !/ti{f�/� - �C Address =s �'dyJ�l} `�+'x'4`0 �d? ` <br /> z Owner l Addr Os /I/ /U. fYJ.f�it�f/ <br /> L) Firm Partners, Addresses and Telephone_Numbers —� <br /> aBusiness Telephone No. _A.2,4 66 Emergency Telephone No. <br /> Contractor Licence No. I <br /> LApplicants Name(Print} 3��Q�Np�'A �Q^ ' Title �� Date <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) r a <br /> Serial No. CAL. License No. _. -- CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. t <br /> Equipment Parking Address a <br /> 2. ❑ PUMPER YARD I <br /> 3 <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. c <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT _ .. <br /> Job Address cation O 66 + `�����/v <br /> Owner r ) Address F <br /> SEPTI TANK 1iSSPOOL LEACHING FIELD C1 SEEPAGE PIT. PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> a <br /> Type Construction I Disposal Site �; <br /> No. of Units Equipment Storage/Cleaning Location(s) m� <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,- June 30, 19 <br /> Operator Name - Where Certified <br /> w <br /> Plant Location <br /> s <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 /> A - <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I <br /> ordinances, state laws, and rules a s of a San Joaquin Local Health District. <br /> } <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY 7, I <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 /> BILLING REMITTANCE $ 1 <br /> BASE- EXPLANATION AMOUNT DUE CHECKED <br /> C i DATE -DATE REMITTED AMOUNT - <br /> FEE f v* <br /> LESS <br /> PRORATION <br /> PLUS = <br /> PENALTY <br /> _ OTHER <br /> -`'OTHER <br /> ReceivedW Receipt No., Permit No. lssba=6 Date Mailed Del' ered <br /> APPLICANT—RETURN ALL­COPIES TOC ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.-HAZELTON AVE:;P.O.Bax 2009 ST CKTON, A 95201 j <br />