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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> A� APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> E ( $ to ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> r [ l-(o`Z i LIQUID WASTE <br /> Application Is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District y <br /> y Business Name (DBA) , A^/Th o/yc -+' :5o' .0 Address '�C' aox al io /"/c,-1eS!d <br /> aOwner .4 e e '0"V Address Si9iMe <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 3`yA Emergency Telephone No. s 2 J wc5 3 �0 <br /> aContractor Licence No. o� ,YsscTorDate <br /> L Applicants Name (Print) �� /�.r-?/S�n-y Title <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:lse Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking-;Addt.ess <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. 19 SANITATION PERMIT <br /> Job Addresss/2/Location 4o7- /,91.zl J'_-444-oval g� SAS r/a!-3�0/'V Y'�yC"" c L.y , <br /> Owner —�✓ O2Y4 e C7'ou/eAL- Address 0'22 o,a,�v�.y 57-, /t7'4_'r Te C. <br /> X SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHER F/L TAY /3rd <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 /> 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 rules d ion of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATU X <br /> J . <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 .5172/ <br /> LESS c•' �J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER C1. <br /> OTHER <br /> Received by Date Receipt No. Permit No. -1 uance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />