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r�rr ...,,..n� r•m ue el uceeseu wmm Submitted Property %;ompleted. be Sure T•- Sign The Application. <br /> APPLICATION .d <br /> (Foo"Won-Transferatch, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made I c r[y gn,busjn ssi the juri{d�ictional area of th„KSa Joaquin Local Health District <br /> Business Name (DBA) L 1= F W�'} ` I'}{�i) r 1�. h OCA-dress lV� �t <br /> i Owner I_ E-(�w, R�T }�Q \ Address 3 SQ % f ,P% a TO rti ) <br /> Firm Partners, Addresses and Tolephone Numbers <br /> iBusiness Telephone No. Emergency Telephone VV\ �. <br /> Contractor Licence No. _ L <br /> r J <br /> LApplicanis Name (Print) L-." - 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 Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liczise Renewal No. <br /> Capacity Gal.,Weights&Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD ^ <br /> For July 1, June 30, 19 V. <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST C <br /> R.S.or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/cation S L F _ r <br /> Owner �t ' Y`T Address 5 �►'( <br /> SEPTIC TANK ❑ CESSPOOL - firLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT �L <br /> PERMANENT ❑ TEMPORARY WNEW ❑ 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 1.21 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certif^41I <br /> have prepared this application and that the work will be done In accordance with San Joaquin County <br /> ordinances,st ,Is nd rule regulations f the qn,Daquin Local Health District. <br /> APPLICANT'S SIGNATURE `Xl \ <br /> . FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January Rec eore a u ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION DATE DATE I TED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S <br /> LESS [/ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dale' Receipt No. Permit N ua c Dale MailedDal' <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,PA.Sm 2005 STOCKTON, W <br />