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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 Suspendabie) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> —LIQUIWWASTE <br /> r Application i hereby made to carry n bus(ness in the jurisdictional area of the�San Joaquin Local Health District <br /> H Business Name (DBA) L �i7PLG L.�INQP 76' Addrass I3 oX <br /> aOwner L. SCG 14 e' rAddress -0. tkx 1 <br /> Firm Partners, Addresses and Telephone Numbe s <br /> ILBusiness Telephone No. O 77 �� r Emergency Telephone No. oZO�� <br /> Contractor Licence No. <br /> Applicants Name {Print) JlNl�L I L +KL=2r Title0X0' <br /> bate /D 1 <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 I <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. ❑ SANITATION PERMIT t/� <br /> 'Job Address/Location g S ( L.A.' I~AD L,,� •C b4 Q ! <br /> Owner NA l.D GK eACF 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) M <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified `_ h <br /> Plant Location <br /> Plant Capacity No. Units Served 1 <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, tate laws, and rules and reg tions of the 5a ocal Health District. a <br /> APPLICANT'S SIGNATURE X P <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 J&1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT (: <br /> BASE ,I EXPLANATION - AM NT D CHECKED <br /> DATE DATE REMITTED <br /> �qT <br /> FEE {? Lks *q J <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY .i <br /> OTHER <br /> k <br /> OTHER I <br /> t <br /> 96 .533 a_ 0 33 6 76-� <br /> Received by Oate Receipt No, Permit No. Issuance Date Mailed D ivered f <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2005 STOCKTON,CA 06201 .� <br />