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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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPlAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Address I! <br /> y Business Name (DB ) I <br /> z Owner Address Q� <br /> u Firm Partners, Addresses and Telephone Num¢ers ��>;f �-- <br /> a P-3g- 7—3 1 Emergency Telephone No. <br /> EL Business Telephone No. <br /> Contractor Licence No. <br /> 1,2 2 p0 <br /> Applicants Name (Print) 'OL kw44-t2 Title Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information p(} <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites _ <br /> Description(Make/Yr., Color) <br /> CAL. License No. CAL. Renewal No. <br /> Serial 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 Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Date/Time <br /> Test Location <br /> � SANITATION PERMIT <br /> Job Address/Locatio �� J8`��+' <br /> Owner Address ' <br /> *SEPTIC TANK C3 CESSPOOL KLEACHING FIELD 11 SEEPAGE <br /> SEEPAGE PIT 13 PACKAGE PLANT <br /> ❑ OTHER <br /> 13 PERMANENT ❑ TEMPORARY ❑ NEW REPAIR � <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 Y <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 /> 4 <br /> f <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 wit San quin County <br /> ordinances, state laws, and rules and reg ation othl ,eA anJoaquin Local Health District. $� <br /> APPLICANT'S SIGNATURE X <br /> I C `¢Cts <br />�I 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE yS� `Y5 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I <br /> OTHER <br /> - OT/HEE�R / �1 q n �`-'�} �q q <br /> /7? e I c - Pte-LlyU �V ( <br /> Received by ate Receipt No. Permit No. Issuance Date ail Delivered <br /> t - APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.MAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9 1 <br />