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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 Suspendabie) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local HeaRh District <br /> H Business Name (DBA)_��' gr () Lar k"'� Address 24'BIQ N. Ke►�vUt �k ReaeQ <br /> aOwner S 2N+.e_ Address Rb <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 33+-1 b6o Emergency Telephone No. <br /> Contractor Licence No. rr / _ <br /> a Applicants Name (Print) �/�10.un1 S ►^+ . ecwlu�h �y c-6,.—S G.'s itle E/", M5'✓r Date 71t 9 1 <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 Phemical Toilets Stored <br /> 3. 09/PERCOLATION��'�T````EST _ <br /> R.S. or R.C.E. Name V` ,, S»,.� L. R.S. or(R.C. Z F3Z''l8 S� <br /> -�I6 K� Ve�h << Test Date/Time W '7 / )jo. <br /> Test Location — :3Driwr— BO PPI <br /> M <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 _ <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 appl tion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. <br /> APPLICANT'S SIGNATURE X Title Date //L <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 S Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> {� DATE q DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PI IIS � t� 2 <br /> �Gw CVY L <br /> OTHER <br /> OTHER <br /> Received y'+7 F2 Date Receipt No Permit N" Issuance Date Mailed Delivered <br /> APPL AN <br /> [--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />