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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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of thej�an Joaquin Local Health istrict <br /> Business Name (DBA) Address e• 90k I' —IW 4Z"141_0 ` 3-Z-d>/ I If <br /> z Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. _ � - ?607 Emergency Telephone No. t <br /> Contractor Licence No. zs —3-443 i <br /> L Applicants Name (Print) S Title QST/A",*7_62, 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 1AI <br /> Description(Make/Yr., Color) <br /> Serial No. rl CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address i <br /> 2. ❑ PUMPER YARD of <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored Y <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. 931SANITATION PERMIT c <br /> Job Address/Location ��� S, TQiV / / RC1 _ <br /> Owner i2l/ll� /eA '� Address o Gt �S� CKJ <br /> ❑ SEPTIC TANK ❑ CESSPOOL BLEACHING FIELD CIISEEPAGE PIT 0 PACKAGE PLANT 06 <br /> B"PERMANENT ❑ TEMPORARY ❑ NEW C'REPAIR ❑ OTHER d <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 a } <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s)_ �P <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 1 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 4 <br /> 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, nd rules and guiati pfthe S JoaquiQ Local Health District. <br /> APPLICANT'S SIGNATURE <br /> I3 <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> d 4 <br /> FEE S✓ <br /> LESS <br /> PRORATION <br /> PLUS I <br /> PENALTY / <br /> OTHER ` - ... .... ' <br /> a - <br /> OTHER ' <br /> ar3 o. <br /> Received by Date Receipt No, Permit No. I Is anteto Mailed Delivered J <br /> r <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTp .,P.O.Box 20U9 STOCKTON,CA 9 1 <br /> 1 — <br />