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ionswillorocesseawnen SupmllledProperly Completed. BeSureTo SignTheApplication. <br /> - ,( APPLICATION <br /> ;I (For Non-Transferable, Revocable, and Suspendable) r <br /> f' ENVIRONMENTAL HEALTH PERMIT 1 SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin L6 H t DI <br /> y Business Name (DBA) '�1JG. Address _ 5`2. <br /> k, <br /> a Owner Address <br /> Firm Partners,Addresses and Telephone Numbers <br /> a.;Business Telephone No. --.. Emergency Telephone No. <br /> i'Contractor Licence No. <br /> L'Applicants Name (Print) �.... 13—Z-3— <br /> 15 SIMS Title��L�+(�"T�� Date <br /> Please check Applicable Category(1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) l r <br /> i .For July 1, June 30, 19 Disposal Sites <br /> !Description(Make/Yr., Color) CK <br /> liSerial No. CAL. License No. CAL. License Renewal No. <br /> ,,Capacity Gal., Weights& Measures No. <br /> Equipment Parking Address <br /> f `2. ❑ PUMPER YARD <br /> IlFor July 1, June 30, 19 <br /> l <br /> ::No. of Vehicles Stored <br /> M I No. of Chemical Toilets Stored <br /> } 3. ❑ PERCOLATION TEST <br /> : <br /> I <br /> IR.S. or R.C.E. Name R.S.or R.C.E. No. <br /> 'iTest LocationTest Date/Timee. <br /> 1`4. � SANITATION PERMIT <br /> .Job Addressocation - -. <br /> i�Owner /M x x _ Address <br /> 2'SEPTIC TANK ❑ CESSPOOL 3'LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT CA <br /> I 9-'PERMAN£NT ❑ TEMPORARY 8 NEW ❑ REPAIR M-157THERCZ) �S <br /> :y5. ❑ CHEMICAL TOILETS For Juty 1, -June 30, 19 y <br /> ijType Construction Disposal Site _ <br /> 3� :�zs PiTrs <br /> 11No. of Units Equipment Storage/Cleaning Location(s) <br /> & ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> :Operator Name Where Certified <br /> ;Plant Location <br /> i;Plant Capacity No. Units Served <br /> I+7. 11 LAUNDRY For July 1, -June 30, 19 <br /> ;,SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. N <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 7 <br /> i, <br /> i <br /> a 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 s.and re? <br /> e ations of t an Ja in L cal Health District. <br /> SAPPLICANT'S SIGNATURE <br /> �i <br /> [' I FOR DEPARTMENT USE ONLY <br /> 9 Fee Is Due: ❑ ANNUALLY © PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July I &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ <br /> DATE DATE REMITTER AMOUNT DUE AMOUNCHECKED <br /> FEE Q <br /> :I <br /> I! LESS O- <br /> i PRORATION zillf� <br /> i <br /> PLUS <br /> PENALTY <br /> r r: OTHER <br /> OTHER _ <br /> 31-Q� <br /> Received by Date Receipt Na. Permit No. ssuanc Dat< kyd Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITfSERVICES 1601,E.HAZELTON AYE., . ox 2009 STOCKTON.CA 95201 - <br />