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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 Suspendabie) <br /> ENVIRONMENTAL. HEALTH PERMIT 51 PTAGE <br /> k° LIQUID WASTE <br /> _ Application is hereby-made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) , _ Address.. �� sarae �• <br /> ti��l L7 <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers_/ <br /> M1 a. Business Telephone No. e ��!] / Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) 4. 1.!"Y<<G�O� Title 4:w•/yc��; _ Date�� — �L5— <br /> Please check Applicable Category (1-7) and Fill in the Required Information p1 <br /> z 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) yv <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. License Renewal No. <br /> ' Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, _ June 30, 19 <br /> tof-Vet�idles Stored' . �-- j <br /> of <br /> Chemical Toilets Stored " <br /> 3. ❑ PERCOLATION TEST w <br /> R.S. or-R.C.E. Name R.S. or R.C.E.,No. \ <br /> • Test Location Test <br /> Date/Time-4. ❑ SANITATION PERMIT _ k 0O <br /> v Job Address/Location T D 6 l D&4 <br /> Owner - 77-7 D_ n657_- Address A49 AiF io <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT .❑•PACKAGE PLANT <br /> F <br /> 11-PERMANENT ❑ TEMPORARY ❑ NEW [3-REPAIR ^❑ OTHER <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 _ 4 Where Certified <br /> x Plant Location . <br /> Plant Capacity - No.�Units Served <br /> f 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> t SIZE: '❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. b' <br /> r ❑ DRY CLEANING, Chemicals Used/Amount/Mo, <br /> h 1 <br /> t k <br /> fy r�r.car.-a�w•M-�w�. —am. .r - _ r _ <br /> E !' r • <br /> d hereby certify that I have prepared this application and thatAhe.w_ork will be done in accordance with San Joaquin County i <br /> ordinances, state laws,'and rules and re ulations of the San Joaquin Local Health District. <br /> , <br /> APPLICANT'S SIGNATURE X <br /> 4 - A FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY '❑ PER UNIT _❑ PER-SITE ❑ EACH ❑ JanAy 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE..: EXPLANATION BILLING REMITT $ AMOUNT DUE CHECKED <br /> DATE DAIV REMITTED AMOUNT <br /> FEE-'_�_ - <br /> - $ + <br /> LESS - <br /> PRORATION! F ub-• 1f <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> i APPLICANT-RETURN ALL COPIES TOc ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201�, t� <br />