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Applications WIII Be Processed When Submitted Properly Completed. Be Sureo Sign The Application.iG� I <br /> APPLICATION M <br /> IF, m-Translerable,Revocable,and Suspendable, <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> I <br /> Applidatlon is hja®reby made to carry on usiness in the jurisdictional'area of the So oaquin Local Health District <br /> Business Name (DBA) :. .�.: Address �Jo_. f L.�CjV %GAc <br /> FZ Owner4 .L.1=y_L4:L: �2 'lr' Address's Gam' 6��•_w�'?i_=v/--'`Y.t'T. <br /> Firm Partners.'Addresses and Telephone Numbers • . -ac ' <br /> iBusiness Telephone No. Efrlergency Telephone No. <br /> Contractor Licence No.T.,;_L 2 <br /> Applicants Name (Print) , 1 " 5' LGc n- Title Date —�—�h <br /> Please check Applicable Category(1-7)and Fill In the'Required Information a <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR*EACH VEHICLE)' 1 <br /> For July 1, June 30. 19 - Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. — CAL:,License N0. CAL.License Renewal No. , <br /> Capacity Gal.,Weights 8 Measures No. <br /> • r <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD �+ <br /> For July 1, June 30, 19 -0 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST - <br /> R.S. or R.G.E. Names R.S. or R.C.E.NO. <br /> Test Location 1, Test Date/Time , <br /> 4. ❑ SANITATION PERMIT y II <br /> Job Address/Locatio-nom � '�� '� <br /> Owner Di �,A eKI <br /> g � i .� Address ��'�'1�' 475'✓ �, <br /> ❑ SEPTIC TANK' <br /> I❑ CESSPOOL ❑ LEACHING•FIELD E PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY P NEW EPAIR 11. OTHER W <br /> S. ❑ CHEMICAL TOILETS For July 1,.-June 30, 19 W <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 S <br /> Plant Location rr`Illl <br /> Plant Capacity No. Units Served l <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 '+•• - Q <br /> SIZE: ❑ Less Than 1,000 Sq.Ft., ' ❑ More Thari 1,000 Sq. Ft: <br /> Ei'hRT�c�P.olChemicals Used/Amougt/Mo. <br /> 1 hereby certify that I have prepared this applicatiop and that the work will be done in accordance with San Joaquin County <br /> ordinances;state laws, and wllees and re latioof:the,5 Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOUR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑PER UNIT ❑ PER SITE"'. . ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> y <br /> BI LING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 95 r7' <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY It- <br /> OTHER <br /> r <br /> OTHER <br /> 65sa �3 � <br /> Received by Date Recmpt Na. Perms No. Ilisuance Date Mailed fiCelivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 200 STOCKTON,CA 95101 <br />