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Applications Will Be Processed When Submitted Properly Complete Sur To Sign The Applica I <br /> _ APPLICATION SPR 8 1980 <br /> j_ (For Non-Translerable, Revocable,'and Suspendable) y <br /> ENVIRONMENTAL HEALTH PERISAN JOAQUIN ( O('qL SEPTAGE <br /> LIQUID WASTE HEALTH DISTRICT <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) ` l J Address <br /> a Owner OLA&D.. W, L.A P�L 1r Address 3Q / SD: LA !'J L _ <br /> M Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 0✓$ Emergency Telephone No. <br /> • � Contractor Licence No. <br /> L Applicants Name (Print) O L 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 <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 r <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. ❑ SANITATION PERMIT ++ h r <br /> Job Address/Location �� 3 f so <br /> Owner L_ W, L L a Address .. 5{ Im _ <br /> 0 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT r <br /> ❑ PERMANENT 0 TEMPORARY ❑ NEW 0 REPAIR OTHER 04p f -25c <br /> F 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 /> t Plant Capacity No, Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> r SIZE: 0 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, les d reg 7t!op4 of the San quin Local H al I4 District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 0 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> . BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE 'DATE REMITTED AMOUNT <br /> f FEE 117S ��. <br /> LESS <br /> PRORATION j W� <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> 10 72 5_3 YO <br /> -Received Received by Oate t- Recei t No. - Permit No. . Iss ante Date Mailed elivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 .' <br />