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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 4 <br /> -k APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> �. <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Appl ication is hereby made to carry on business in the jurisdictional area of the.San Joaquin Local Health District <br /> ,F Business Name(DBA)_�� LAS 4/�5..��!/f' /s�.�,/ Address T <br /> a Owner Address <br /> _ . <br /> 1 Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. - -71 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Jiz'LD XD t. . �✓✓O4_ 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. Licensd No. CAL. License Renewal No. s <br /> Capacity Gal.,Weights &Measures No. t <br /> Equipment Parking Address f <br /> 2. ❑ PUMPER YARD <br /> For July 1, . June 30, 19' <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored V �- <br /> 4 ; <br /> 3. 11 PERCOLATION TEST. <br /> R.S. or R.C.E. Name. - R.S. or R.C�E. No. - <br /> Test Location a ""r.'-. Test Date/Time <br /> 4. 9 SANITATION PERMIT <br /> Job Address/Location 361049 Z221A&C AZ LA.t/, <br /> Owner aoe Address <br /> LM SEPTIC TANK: ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑TEMPORARY NEW ❑ REPAIR_ ❑ OTHER t ' <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Constructionv r <br /> Disposal Site •`_ <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 n1. <br /> Operator Name t� 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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ' <br /> I hereby certify that I have prepared this application an the work will be d6ne in accordance with San-Joaquin County <br /> ordinances, state laws, and rules and regul tions of the an J aquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> s <br /> - FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ; ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE $ REMIT A <br /> BASE EXPLANATION PATE �DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT a <br /> FEE 4 C' O 7 <br /> J t] <br /> LESS 4 <br /> PRORATION I• a <br /> PLUS <br /> PENALTY <br /> -OTHER <br /> OTHER !' <br /> Received by Date Receipt No. Permit No. ssuan a Dae Mailed , Delivered , <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT%SERVICES 1601 E.14AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br /> 7 <br />