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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 G <br /> 0 LIQUID WASTE „p <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) 'Gi /)n'//7onev 4- ,Soni Address P, 0, Cox -1/0 9`70rles'rO 9'x-35'1? <br /> aOwner L cr. Address SAtitC _0 <br /> J Firm Partners, Addresses and Telephone Numbers _ <br /> aBusiness Telephone No. sR3—�/��'7 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) 4 4,v76 ez'y Title Goy-Tr e jA r 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 I <br /> Description(Make/Yr., Color) C) <br /> Serial No. CAL. License No. CAL. Lic:nse Renewal No. i <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. S <br /> Test Location Test Date/Time <br /> 4. IV SANITATION PERMIT <br /> Job Address Location '�- p�3 /�?'>HiJ�� � .SAV 0'4 vi iv <br /> Owner L N Address e <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW .Iff REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleanin"ocation(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ca <br /> Operator Name .Where Certified a� <br /> Plant Location c� <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 done in accordance with San Joaquin County <br /> ordinances, state laws,and rule nd regulations of the San Joaquin Local Health District. <br /> x <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED' AMOUNT DUE CHECKED <br /> AMOUNT <br /> O� <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Re eipt No. Permit No. ssuance 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 />