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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 /> tar ``) LIQUID WASTE <br /> Application is hereb made to carry on business in the jurisdictional area of the an Joaquin Local Health District <br /> OF Business Name (DBA) �� �ret;�K ge- S'riY Address STe' G� <br /> i Owner A -ev Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. s'Z�� �x Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) ��r ��c'T,�a�-tom Title �� Date '� _� '�- g0 <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. Liccase 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 O <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location 30 oao A,o5.ow I;cl 4 or 314 !J -57AWTpio�crj y /8;✓eY C��L <br /> Owner Cb,-f,7-e>, kf-' Address S.raiy c <br /> ® SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY F. NEW ❑ REPAIR W OTHER I=:"L Tar dc-c/ 4 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 Z <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 /> 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 ru s and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Pr 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 L' �— <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date 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 21109 STOCKTON,CA 95201 <br />