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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 24- APPLICATION 90 7 S <br /> (For Non-Transferable, Revocable, and Suspendable) -P r ,•- ��``J <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 Health District <br /> y Business Name (DBA) Da/e�/►E5AC-114 PII�ZZ,A Address N7 '-:::�T IDI c�. 4rJ�40 <br /> a Owner "TIP�FNPI-X 9)&'ZZA Address a 32� vV (.t/l -:7T. L D1 GIS. 952470_ <br /> j Firm Partners, Addresses and Tele hone Numbers '16? - �� L <br /> aBusiness Telephone No. J10 -�O�O $ Emergency Telephone No. 3109" �o 94 <br /> Contractor Licence No. <br /> L 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 StoredPA AA�� <br /> 3. R PERCOLATION TEST n R�� {ir <br /> R.S. orQ-C�,/.E�Name R.S. or .C.E No. <br /> Test Location 13 9 L6-2)ST TRF--';r- L: SD Test fate/Time <br /> 4. ❑ SANITATION PERMIT SAN�OAQUrN CO <br /> Job Address/Location I <br /> Owner Address UNMOVIAL SER T <br /> C1 SEPTIC TANK 11 CESSPOOL 11 LEACHING FIELD El SEEPAGE PIT ❑ PACKAGE PLANT D(VISIOn! <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site �J <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 C <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. If <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a�=" <br /> d r`egu�lations of San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X I/ , �'' � - <br /> C---)T — P612,CEL <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE c DATE ,REMITTED AMOUNT <br /> FEE_ � .� � t -1 �'. � �l. .� ��]L.,Q.. `CXS <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> � �-•��/ <br /> 1 1 F Sr' I •�` �� <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 />