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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 h reby made to car on business in the jurisdictional area of th San Joaquin Local Health District <br /> O Business Name (DBA)Dk. } � � ��?�- Address <br /> z Owner Address <br /> e <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Z5 <br /> Contractor Licence No. !Z���O <br /> L Applicants Name (Print) S-rA k? t 't Title g`t'-1 4 n Date _-2 <br /> Please check Applicable Category (1-7)ark Fill in the Required Information ~` <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) `? <br /> For July 1, June 30, 19 Disposal Sites ;i <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No." ` CAL. License Renewal No.E�7�1 <br /> Capacity - Gal., Weights & Measures No. , <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 b <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 /> Tests Loo ion Test Date/Time C114. la SANITATION PMIT <br /> R <br /> Job Add r /Location —(Pq 3 1 <br /> �� <br /> Owner �-�Q..T ���91.E � Address gsr7 <br /> SISEPTIC TANK ❑ CESSPOOL O LEACHING FIELD 1❑/SEEPAGE PIT ❑ PACKAGE PLANT GJ <br /> PERMANENT E] TEMPORARY 3 NEW lJ 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($) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified R <br /> Plant Location <br /> Plant Capacity No. Units Served - <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ac- <br /> SIZE © Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. i <br /> e <br /> I hereby certify that I Ire prepared this application and that the work will be done in accordance with Joaquin County <br /> ordinances, state laws, rulesa0d regu ns of t Sin Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X -. <br /> FOR DEPARTMENT USE O LY �t <br /> Fee 1s Due: 11 ANNUALLY El PER UNIT 1:1 PER SITE 13 EACH ❑ Janu y 1 eived By January 31' ❑ July 1 &Received By July 31 P <br /> REMIT <br /> BASE EXPLANATION BILLING REMI AN $ AMOUNT DUE CHECKED <br /> DATE REMITTED AMOUNT <br /> �5 <br /> FEE � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER i <br /> .�. g �C <br /> Received by Date - Receipt No. _ Permit No. Issuance Date . Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.;P.O. oK 2009 STOCKTON,CA.95201 <br />