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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <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 <br /> CAF Business Name (DBA)�,lJ_5�J ` ai✓ 1 'Q f <br /> I- - _ Address <br /> i zz Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> ILBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. rA_15194 <br /> L Applicants Name (Print) ELt9 a Q Title ea/ Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Matte/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 /> I <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 /> Testi Location Test Date/Time <br /> 4, 0 SANITATION PERMIT <br /> Job Address/Location <br /> Owner 2 ?C,"P_Z5 L_ S//17 A%41_ Address <br /> SEPTIC TANK <br /> 11 CESSPOOL 1K LEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY D4 NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 y <br /> Type Construction Disposal Site �1 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t <br /> Aerator Name Where Certified , <br /> Plant Location`' 4 <br /> t I <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. a <br /> ❑ DRY CLEANING, Cherhicals Used/Amount/Mo. <br /> r <br /> 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 rules and regulation(VSan Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONL <br /> Fee Is Due: ❑ ANNUALLY [],PER UNIT ❑ PER SITE - ❑.EACH ❑ January 1 &,Received By January 31 ❑ July 1 &Received By July 31 <br /> i <br /> SASE EXPLANATION BILLING EMITTAN $ REMIT F <br /> DATE D REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS (� <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> P13 A, <br /> Received by Date Receipt No. Permit No. - ISsu nee D Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.'HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />