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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 2C y I ,APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> 4 ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is_hereb made to carry on business in the jurisdictional area of the San Joaquin Local Health District W-9.5 <br /> w Business Name (DBA) —A NT/5 a n�Y Address ' �' /3p X 1 1 �d <br /> aOwner Address <br /> J Firm Partners, Addresses and Tele hone Numbers <br /> aBusiness Telephone No. � 3 `T Emergency Telephone No. <br /> Contractor Licence No. -5—A? 6 <br /> I <br /> L Applicants Name (Print) Title 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. Licc.nse 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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. X SANITATION PERMIT `Q <br /> Job Address/Location 3 a000 A�q SSON Rc/ Q y <br /> Owner eFi G,4 e/ Address L`'7- V--- = z 3 .��/M Sl C <br /> Bl SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT D <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW WREPAIR ❑ OTHER "L r�3 ls'e 9V <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 /> t <br /> t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance wit Sa Joaquin County <br /> ordinances, state laws, and rules 9d regulations of the San Joaquin Local Health District. <br /> APPLICANTS SIGNATURE X �7 g/ <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE -S LL p T <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by bate 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 />