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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ppo6l y ane APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> q2. )b ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) 'F A417A &1VY V5041 Address P0, CBOT 1/0 moedcs Tp 9.S3S3 <br /> a Owner ee Address <br /> 9A/r/fo�Y <br /> Firm Partners, Addresses and Telephone Numbers (\ <br /> aBusiness Telephone No. s�3-Y��� Emergency Telephone No. <br /> Contractor Licence No. /LG- SFl6 7 <br /> L Applicants Name (Print) A e e Title GC/11725,9 c jo y 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. Liccnse 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. ® SANITATION PERMIT AQ <br /> Job Address/Location g�?�000 „95901� C� 1.b T /'g—6 /�f'Py STo�Yr� ��e® <br /> ryy)cy _ <br /> Owner 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 Flx X-> ae d <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 r <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 b <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 K <br /> ordinances, state laws, and r s and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X A <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 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY Z3 <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Is uance Dat6 Mailed ered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 9009 ST CKTON,CA 95201 <br />