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Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application.�.. <br /> ` ' APPLICATION <br /> ' I• (For Non-Transferable, Revocable, and Suspendable) '~ -- <br /> i� ENVIRONMENTAL HEALTH PERMIT SEI'TAGE <br /> LIQUID WASTE <br /> y Application is hereby made to carry on business in the jurisdictional area of the San oaquin Local Health District L� <br /> F Business Name (DSA) 1 L� 6 ,A- ddress " -4 �. [,/�( ,Qee- 4eRy7FW <br /> a <br /> Owner—LX4PeA"C e ;4%5!1�_ex_ Address <br /> Firm Partners, Addresses and/Tel h ne Numbers <br /> aBusiness Telephone No._ � � Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name {Print) <br /> 4"e—_!r-Title Co �3 �� <br /> Date�' - -2 7— — ._ 0 <br /> Please check Applicable Category(1-7)and Fill in the Required Information r. 5 3.T{C Fu c VVE.R SERVEG <br /> CL�.1t I.CI�'S <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) c c,.n <br /> For July 1, June 30, 19 11 Disposal Sites , o.• Grp t ktG , C8i f 95205.,". <br /> Description{Make/Yr., Color} it <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> } 2. ❑ PUMPER YARD li <br /> For July 1, June 30, 19 �. <br /> No. of Vehicles Stored _ ... <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST is <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> I Test Location Test Date/Time <br /> l 4. XSANITATION PERMIT <br /> I Job Address/L t!on A <br /> O�pwner Ij Address <br /> JAS SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGI NT <br /> PERMANENT ❑ TEMPORARYNEW 11REPAIR ❑ OTHER <br /> 5. El CHEMICALTOILETS For July 1, -June 30, 19 <br /> Type Construction 4 Disposal Site ~� � <br /> No. of Units 1l. Equipment Storage/Cleaning Location(s) Q <br /> fi. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name i -_- Where Certified <br /> Plant Location <br /> 1 Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 1 `+ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount'/7Mo. r <br /> � <br /> f� oiio ''w liCi l r 11(. J il <br /> !C <br /> r F1-,4a3 Z._`iJ9 <br /> it <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, an d regulations of the n Joaq in Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY i€'❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> - II BILLING REMITTANCE $ REMIT <br /> BASE x EXPLANATION AMOUNT DUE CHECKED <br /> r1. DATE DATE REMITTED AMOUNT <br /> FEELESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER �i._ _ sw-•" _ -' -`. a_<. _ i <br /> i <br /> OTHER <br /> o3� � oar � �7 � 3 <br /> Received by Date Receipt No. - Permit No. Is uance Date Mailed De were , <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.O.Box 2009 STOCKT N,CA 9 01 1- <br />