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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) I <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID 111i <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA). 4417/S 'r' e` Safi/ Address <br /> zOwner Address . <br /> _Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. -9--z 3 ~ V12 Emergency Telephone No., <br /> Contractor Licence No. !G 6 -�"S G <br /> L Applicants Name (Print) Title Date 22"_/0—S-2 <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 — Of <br /> Description(Make/Yr., Color) I �, <br /> Serial No. l CAL. License No. CAL. Liccase Renewal No. 1 <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> �:. <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored l <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location I Test Date/Time <br /> 4. R SANITATION PERMIT <br /> Job Address/Location II.611 <br /> Owner 15-19 /10'//7,��ivy;I Address <br /> t 11 SEPTIC TANK ❑ CESSPOOL_ ® LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ® PERMANENT El TEMPORARY}', ® NEW ❑ REPAIR ❑ OTHER - 9 <br /> F 5. ❑ CHEMICAL TOILETS For July 1 -June 30, 19 <br /> Type Construction I Disposal Site S <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> E 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> # Operator Name Where Certified <br /> ( <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 les and regulations of the San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> r <br /> M <br /> _ FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 3111 July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> LESSPRORATION <br /> 1 PLUS <br /> PENALTY <br /> 1� OTHER t <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 2009 $TOCKTON,CA 95201 <br />