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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) SEPTA(-,r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE /'h qZ —31 <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Loc rict <br /> y Business Name (DBA) k INC—, Address 2 2� <br /> Owner tz Address 11�GGi MIC"_ Gf'O✓ff Rb <br /> 14 <br /> U Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. �l <br /> a Applicants Name (Print) t^ffi97L(�Li� �, ��/(/ Title ��.19MI Date -21-0 JOV <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. 0 PERCOLATION TEST _ � <br /> R.S. or R.C.E. Name ©A/4t� /AV7t R.S. or R.C.E.. No. 3$8 <br /> Test Location I/Zlvro /1?1CLC 6v0e0"` Test Date/Time '27 AJO 30 <br /> 4. ❑ SANITATION PERMIT <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 i <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name <br /> 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 /> NOT°O>N11e► ++sedsgent's:ignaN,�,y,nieathefpl)owi I C-rtifyf - - <br /> tn such manner as to beCOMC subixi to worRi1an s c"Penwio:l s of;'.1t;t h in the Worms"of <br /> thework for which <br /> COn.ractor's hking or mrb-caltractinrl sacrn�trWn wt:=an• t Itta" psialitls i95eet1.I_h311rrot amptoy any person <br /> PAY persons subject to wurkaiau 5 t:C, tom; rollo.yN,y: I cec..`y that rn the Perfor,nar:ce;,;i! v, rk for which t s permit is is pec.!,hall <br /> "tl j <br /> m;h:rlsation laws ut C::Iit;,�Giy� •� . -- . o <br /> I hereby certify that I have prepared this applic4ion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regula ' s`ZdfZnoaquit),,,Local Health District.APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ P R SITE ❑ EACH Jan 1 &Received By January 31 11 July 1 &Received By July 31 <br /> BILLING REMIT <br /> BASE EXPLANATION E $ F:�7 CHECKED <br /> DATE DATE ;ITT;/ AMOUNT <br /> FEE " � e, � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Fieceipt 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 />