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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. T ' <br /> t ; <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> "LIQUID WASTE W <br /> Application s hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health DIStrIC <br /> Business Name (DB­_4949Address 144 &4 r <br /> Owner;, - ,R,6 <br /> '►d%�_/ `Yk.a<�� Address_ c 1 1lVi •s.. -- <br /> Firm Partners, Addresses and Telephone Numbers ._ 5775y <br /> K Business Telephone No. x-56, -�_ Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) 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 34, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. •- ! t i CAS_. License Renewal No. <br /> Capacity Gal.,Weights & Measures No "- <br /> Equipment Parking Address T, <br /> 2. ❑ PUMPER YARDFor July 1, June 30, 19. <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Storedr <br /> 3. E] PERCOLATION TEST <br /> R.S.or R.C.E. Name •`w s R.S. Or-R.C.E. No. <br /> Test Location Testate/Time- <br /> 4. ❑ SANITATION�P ERMIT P • y , <br /> _ 4� l <br /> Job Address/Locati431- fR s ) <br /> Owner VrI1 `r cam..` �.. •t�Address* _ -. <br /> SEPTIC TANK ❑,CESSPOOL 0 LEACHING FIELD ❑ SEEPAGE,PI,T ❑ PAC ArGiE'PL•AIVTk <br /> ❑ PERMANENT ❑ TEMPORARY I9 NEW ❑ REPAIR 0 OTHER S ; <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site r <br /> No. of Units Equipment Sto_rage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name _ Where Certified <br /> Plant Locations <br /> Plant Capacity f No. Units Served <br /> 7. ❑ LAUNDRY iFor July 1, -June 30, 19.- <br /> SIZE: ❑ Less Than 1,000 Sq.�.,, ❑ More Th`an,1,000 Sq. Ft. v <br /> 13DRY CLEANING# Chemicals Used/Amount/Mol.--.- 1 <br /> 9 r' <br /> I hereby-certify that I have prepared this application and that the work will be done iR.accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health Distr'•ict.. <br /> APPLICANTS SIGNATURE X �/ Gl S0 . <br /> t FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY '❑ PER UNIT j PER SITE��_k❑-EACH `I❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 0 I REMIT <br /> BILLING ITTANCE_ $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED k <br /> DATE i- DATE E y REMITTED AMOUNT } <br /> FEE <br /> LESS 4 :1.. <br /> r€ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER } <br /> OTHER <br /> Received by Date Receipt No- Permit No Issuance Date Mailed a were <br /> V _ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 V STOCK ON,CA 9 1 <br />