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APPLICATION <br /> : r Non-Transferable, Revocable,and Suspendabl <br /> `ENVIRONMENTAL HEALTH PERMIT = SEPTAGE <br /> LIQUID WASTEa <br /> Application-iTh,ereby made to carry on business in the jurisdictional-area of the San•J�aquin Lt7cal Health District <br /> Business Name-•(D"BA) i Address / <br /> 4 Owner %-f ►^ Addrgss / ?f F&Ir� <br /> J.Firm Partners, Addressp4nd Telephone Numbers <br /> aBusiness 1 ereption'dWo. '- Ernerg cen y Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) krleEr" A 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 /> Seriai 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 p, <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. 1; <br /> Test Location Test Date/Time (4 <br /> 4. ❑ SANITATION PERMIT j \ <br /> Jab Address/L cation S-3/ -4Cw+oh <br /> Owner t"" Address �c� <br /> SEPTIC TANK ❑ CESSPOOLLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR R OTHER st,v-cja <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 application and that the work will be done in accorda with San Joaquin County <br /> ordinances,state laws,and rules qnd regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: 0 ANNUALLY ❑ PER UNIT PER SITE ❑ EACH .❑ January 1 &Received By January 31 ❑ JJIy 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 777 9 b_3'7tb <br /> z <br /> Received by Date Receipt No. Permit No. issuance ate Mailed ive <br /> APPLICANT--RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 $TOC TON,6 25261 - <br />