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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> r (Far Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> e LIQUID WASTE <br /> Application is hereby made to c rry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) ,� �j Address e&7 / 1`I� l r <br /> 4 Owner S��v hi�-c- GYCCrN Address <br /> a Firm Partrrbrs, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 0 °�' , ,,2 & r�'�, 0.r.239`7,?V07 Emergency Telephone No. 7 – O 3 giL V <br /> Contractor Licence No. ti 66 7dX <br /> L _ 1 <br /> ti <br /> Applicants Name (Print) Title �r �Y` Date ` v <br /> -Please check'Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMfi'VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> kFor July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License Na. 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 /> I` No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name _ R.S. or-R.C.E.No. i+ <br /> Test Location Test bate/Time V <br /> 4)4? ❑ SANITATION PERMIT �t / <br /> Joh Address/Location -- 7 3a <br /> Owner_ Addres <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 /> i <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 accordance with San Joaquin County + <br /> ordinances, state laws, and rules and regulations of the San Joaquin ocal ealth istrict. <br /> APPLICANT'S SIGNATURE X .� <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> �,. p AMOUNT <br /> c <br /> FEE 4f.4f, NS (Q <br /> I LESS <br /> PRORATION ko <br /> PLUS <br /> PENALTY <br /> I OTHER <br /> OTHER <br /> Received by DEfte Receipt No. Permit No. Issuance Date Mailed Delivered <br /> 3 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201�� <br /> � w <br />