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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application juj J e6V mma IQ��rLWy onyuS ID ess in the jurisdictional area oft 3D q Local H h Dist�i- tt , <br /> F Business Name (DBA) In i771V SZ7RSa 1i1C• Addressy�� iern WE ��110Y, 95376 <br /> a Owner Raymond TA Rizuno, etal Address 2oa_,n__Ahern Rei Triiii CA 95376 <br /> 2 Firm Partners, Addresses and Telephone Numbers 209/83515 <br /> aBusiness Telephone No. 209983.5�,K1 K11 Emergency Telephone No. <br /> j Contractor Licence No. <br /> Applicants Name (Pring • Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information p <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. ❑ PERCOLATION TEST y <br /> R.S.or R.C.E. Name R.S.or R.C.E. No. \4) <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT — <br /> Job Address/Locatiop Winteca Ranch Fast of as Ski shed d$ Q <br /> Owner .3 iDOriG To Mlzuno, etal Address 29050 Ahern Road Tracy, CA 95376 <br /> ❑ SEPTIC TANK X1 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 Locations) <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 /> I hereby certify that I have prepared this application and that the work will be (Tone 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 SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION" BILLING REMITTANCE $DATE DATE REMITTED AMOUNT DUE CHECKED <br /> *1� s AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1y1t a l b <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed Deliyerlld <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON.CA 95201 <br />