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Applications Will Be P ssed When Submitted Properly Completed. Be :To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is herebyade to carry n business in the jurisdictional area of the San Joaquin Local Health District <br /> a Business Name(DBA) ��� l,vr� ZM0je_✓H _ Address pD. 'k 21604,00i�4'`� <br /> cOwner_X&E6ul 1 — — - - /--- Address <br /> Firm Partners, Addresses nd fiephone Numbers t_�41_�_ <br /> -10 <br /> CL <br /> Business Telephone No. � ''� t Emergency Telephone No. <br /> j Contractor Licence No. <br /> `Applicants Name(Print) 0 DcL _ Title� O SU'eYE4'��C __ 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 Gat.,Weights ✓3< Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> ------ <br /> No.-?V,hemical Toilets Stored <br /> 3. F6 PERCOLATION TEST _ <br /> R.S. or R.C.E. Name DoE MUt.pttAf R.S. or R.C.E. No. 7 — 41S <br /> Test Location 10$41 Er-, AftOtD000. *,*Aoo Test Date Time �"Z�t_'43 :ETtD �� LAST Ifi41F hbot <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner _ Address ---_ <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ 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 /> 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 n <br /> ❑ DRY CLEANING,Chemicals Used/AmounVMo. ----- -_- -- - -- J / 7, T' -- <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. /�,, <br /> APPLICANT'S SIGNATURE X _ Title"'"�� y' � Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 d Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE r. 0� <br /> .A,, %<--- <br /> LESS ---- - --� - - <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> fill <br /> --- <br /> R Cerved by Date Receipt No Permit No Issuance Date Mailed veered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 25201 <br />