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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 Suspendable) SEPTAG' <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 /> H Business Name (DBA) Saum ach z4 Address 573 W E IM._,rj-r,_ L-0da, <br /> a Owner Address =57 W F� <br /> Firm Partners, Ad resses and Telephone Numbers <br /> aBusiness Telephone No. 36Q 6 d l a Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) r Title �,�,. G , 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 Stored <br /> 3. IM PERCOLATION TEST <br /> R.S. or R.C.E. NameGZZQ R.S. or R.C.E. No. 19436 <br /> Test Location to/Time <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 /> �s p psa }cern; Mzt:••a1' lorrrtantxof"�e +Mkf! " t is permit is issued,!shall net errr)")vinvpersn^ <br /> HornohueMrerr <br /> insucR mammy atto Dsconot totiwrkrtl�nb CWRftiOn fayrerrr., <br /> CMssetoes " or aa1-svnb osrsYie� Ow foM1ovri�: 'cera:,..1�..a fire parformal c,tue work for which this p2nni[is is <br /> mpoy Imp euD}ee!to warkm Wo amp on Uwa of C01"W rda <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 Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY / � <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER S ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION R gGNIL I E GMITTANCE $ <br /> AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> ll f AUGc'q AMOUNT <br /> UG <br /> FEE ��-lJV JV <br /> LESS <br /> PRORATION <br /> r <br /> PLUS <br /> PENALTY �Cn.�rA,IT'SEn ICES <br /> OTHER <br /> OTHER <br /> /oS <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 />