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Applications Will Be Processed When Suh_nitted 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 /> „r Business Name (DBA) A)A,,!7f3oirV Address F a' L?6 x 110 1"ef, .11es j& G/4. <br /> a Owner L` /-ANT 4b I 1 Address ddf92 9�v� G vlr9 �7�t; -lO clot / b <br /> V Firm Partners. Addresses and Telephone Numbers <br /> a. Business Telephone No. ��3� 2 Emergency Telephone No. <br /> Contractor Licence"No. <br /> L Applicants Name (Print) e hz�T/4o�i"�� 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 Sitesl <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licznse 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 C_ <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST r`} (A, <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time ' <br /> 4. 0 SANITATION PERMIT <br /> Job Address/Location Soy "'key AV ,fir 4eV <br /> Owner Ylv/S Address <br /> ID SEPTIC TALK ❑ CESSPOOL IR.LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENTS .,❑ TEMPORARY ?NEW 13REPAIR ❑ OTHER <br /> 5. C'-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 <br /> Operator Name Where Certified <br /> Plant Location <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 /> 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,- d regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> I <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 I <br /> DATE DATE REMITTED AMOUNT <br /> F EE° r >�t�t g t o a }!,A ILN <br /> i <br /> 71, <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY i <br /> OTHER <br /> s <br /> OTHER <br /> Re ei ed by ate Receipt No. 4*rinit4Qo.L I I suance IDate Mailed Delive <br /> f APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 01 <br />