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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> S, J v (For Non-Transierable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> FBusiness Name (DBA) -P,A, A42/?ISbJ Address d'oB,PX J4S'n _'r77-_,c19s'3 f <br /> za Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. !SAG Lo ^ `�Ga-7 Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) Title C57-1­7A2-ax�t Date 2-' 74 <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1.' 11 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. iA <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 �f <br /> No. of Vehicles Stored <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. <br /> Test Location Test Date/Time <br /> 4. 4 SANITATION PERMIT <br /> Job Address/Location Gkl A Lr Aj it T A (?A . 9 <br /> Owner W r /K Z/L R s Address f <br /> SEPTIC TANK ❑ CESSPOOL I.LEACHING FIELD ® SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 r <br /> Type Construction Disposal Site i p� <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 r <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 C unty <br /> ordinances, state laws, and rules and regulations oft an aquin Local Health District. <br /> I <br /> APPLICANT'S SIGNATURE X r <br /> J <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July &Received By July 31 <br /> BILLING REMITTANCE $ / REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> n ♦ "� J <br /> LESS MA:' .�i` . <br /> PRORATION <br /> If <br /> PLUS <br /> PENALTY t I EAe <br /> 146 <br /> OTHER rt >-✓ lt/�• F+A i �� + �. @ <br /> OTHER <br /> 3!-2 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed a iv ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO TON,C 9"01 <br />