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ApFlications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) E <br /> C <br /> ENVIRONMENTAL HEALTH PERMIT /V9 - /[)- <br /> LIQUID WASTE <br /> Application is hherefb ma a to carry on business in the jurisdictional area of the San Joa Di Ict cY � <br /> N Business Name (DBA) ;Clx//v l/��i• __ Address r � l s <br /> i Owner Addr s <br /> a ' �j <br /> Firm Partners, Addresses an ele onepp�u e �� IMA F J A' <br /> aBusiness Telephone No. � j � 4 Emergency Telephone NO. <br /> Contractor Licence No. <br /> a Applicants Name (Print) 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. License 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 <br /> No. of Chemical Toilets Stored <br /> 3. APERCOLATION TES ( <br /> R.S. or R.C.E. Name /V������y� /V R.S. or R.C.E. No. 3�a> <br /> r� 77 <br /> Test Location �1,2k(p /_ , A&r • Test Date/Time �� �C✓ sG/��• —�I�aam <br /> 4. ❑ SANITATION PERMIT e,01 QS4b <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 /> tich <br /> t,7gtban-urthry•a^a,str�_F,gaSlo <br /> ou1;7c.P,E trIS ..Gus7r <br /> 4 9:netahsnNew*ro►aRcsxer •,:'d-a:t•itnePerPr+tanoeeithewxkfor which thspermit isbntator'sfiiriw9, d:emPloy PtrsOtj subtect to 180rtifythatinthepertomissuecy. <br /> fshaf Rotetto aI►YPa- <br /> rson <br /> lifo WOfk fof Whith this <br /> parmii is issued,l;;hall <br /> I hereby certify that I have prepared this applicatio nd that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rvlps and reg do he n Joaquin ocal Health District. <br /> APPLICANT'S SIGNATURE X k�f – <br /> �t�c17 <br /> �. r <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 <br /> q <br /> DATE DATE �REMITTED AMOUNT <br /> FEE r✓� QGS L -27 �.Z o�11 /9 S-0 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -Mg .� /-7S <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.Box 2009 STOCKTON,CA 95201 <br />