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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION -$ Q Q,I 11 G•.G' WODD CO. <br /> (For Non-Transferable, Revocable, and Suspendable) 17F, <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to Barry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA)fJ&Ill / a&LI4 E Q/LZ�7A _ �}, Address '�t �' i�V CL.r,/1 ST L,�pi . GA_ 95240 <br /> i Owner TERRY p/,NZ7_A Address �21 W. EI-M 5m 1-40). Gt\ . 95 240 <br /> L) Firm Partners, Addresses and Tele hone Numbers 31&0 -tn�o/0 � <br /> a Business Telephone No. 3�D `��O)� Emergency Telephone No. �l�q CO 19¢ <br /> Contractor Licence No. <br /> a Applicants Name (Print) Title G Date (:�:p— 14 --q l <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 �1 <br /> Description(Make/Yr., Color) A Yam <br /> Serial No. CAL. License No. _ CAL. License Renewal° <br /> flip- <br /> Capacity - Gal., Weights & Measures No. __ A... <br /> Equipment Parking Address 7 <br /> 2. 11 PUMPER YARD -- PUgl!C N J�HEE JJN cou, ,jrY <br /> For July 1, June 30, 19 — Eti ,'V,R ENr ALr t': <br /> �SE.� ; -. <br /> No. of Vehicles Stored AL NE�11 7r;I, <br /> Noof Chemical Toilets Stored. <br /> 3. a PERCOLATION TEST 9Cv 3 <br /> R.S. or .C.E Name T�P.RY FZ. .C.E <br /> /AR.S. or No. <br /> Test Location 170 1 M. `MM W WY. 'RTE. Test Date/Time <br /> 4. ❑ SANITATION PERMIT +fir I <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ 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(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 ation and that the work ill be done in accordance with San Joaquin County <br /> ordinances, state laws, and es a Tons of the S Joaq ocal Health District. <br /> APPLICANT'S SIGNATURE X - <br /> tRE—M•&INFE�z' <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE Ob Z <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON.CA 95201 <br />