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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application <br /> APPLICATION <br /> (For Nan-Transferable, Revocable, and Suspendable) yy <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> iipulo WASTE <br /> Applicatio s hereby made to cal'on u mess int a jurisdictional area of the San Joaq In Local Health District <br /> O Business Name (DBA) 'AR&I Jc.S �K 4C �� Address ) uTT ► ?� I N. <br /> 1.2 <br /> Owner �� Address ;ANe"e <br /> Firm Partners, Addresses and Tel Numbers 823 'C� <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 3 i <br /> LApplicants Name (Print) 1/�► !`�. 6ZG`�� Title 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 It <br /> Description(Make/Yr., Coloi.) 111 <br /> Serial-No. V CAL. License No. CAL. Lice,se 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'Chem ical,Toilets Stored � <br /> 3. �© PERCOLATION4-EST - - <br /> n+e <br /> R.Sor R:C.EName�g► R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PER O <br /> Job Ad r ss/Coca n _- S 3 L�.TK0- L,��r(RQ �q <br /> Owner he +NJ *. s Address <br /> SEPTIC TANK ❑ C SSPOOL "OLEACHING FIELD 1:1 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY R NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 _ d <br /> Type Construction Disposal Site i <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT Forbuly 1, -June 30, 19 ) <br /> Operator Name f. 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 /> y't <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and t the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,_aDJtw4es and regl}iations he San aquin LocaMealth District. <br /> r !J`J, � <br /> APPLICANT'S SIGNATURE <br /> Vk A s. <br /> .�. <br /> FOR DEPARTVYMEE'NT USE ONLY <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE .❑ EACH ❑ January 1 &Received gBianuary 31 © July 7 &Received By July 31 <br /> BILLIVRE, $ P REMIT <br /> BASE EXPLANATIONAMOUNT DUE CHECKED <br /> DATREMITTED <br /> FEEAMOUNT } <br /> rS t <br /> LESS PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -E 3'M( 7y I <br /> Received by -Date ` Receipt No Permit No, Issuance Date _ Mai]ed Deliveretl , <br /> APPLICANT—RETURN-ALL COPIES TO:' ENVIRONMENTAL-HEALTH PERMIT/SERVICES, 1601 E..HAZELTON AVE.,P.O.Box 200 CK70N,CA 95201 <br />