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Applications Will Be Processed When Submitted Properly Completed. BeSureTo SignTheAppllcanon. <br /> APPLICATION <br /> 7 (For Non-Transterable, Revocable,and Suspendable) SEPSAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE i g <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> L '17A P�®J�i�_6�_ Sd.✓� _ Address 57;41--A) Pe4 <br /> Business Name (DBA) <br /> a Owner <br /> Address <br /> 0 Firm Partners, Addresses and Telephone Numbers <br /> 0. C Emergency Telephone No. I <br /> IL Business Telephone No. GG , <br /> Contractor Licence No. S 3 <br /> F ft !11 1:1. Title 65Tn?A Date—��-"SO <br /> Applicants Name (Print) , <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 x <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. + CAL. License No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address �) <br /> 2. 11 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. No. <br /> R.S. or R.C.E. Name <br />[ Test Date/Time <br /> Test Location <br /> W <br /> 4. )K SANITATION PERMIT <br /> Job Address/Location <br /> Owner <br /> Al " L-& Address .✓SST .S <br /> 11-PACKAGE PLANT <br />" SEPTIC TANK ❑ CESSPOOL 11 LEACHING FIELD 11 SEEPAGE PIT <br /> El REPAIR ❑ OTHER <br />} f PERMANENT 1:1 TEMPORARY <br /> I�, <br /> 5. ❑ CHEMICAL TOILETS For July 1, -'``June 30, 19 <br /> Type Construction tt Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT JFOr July 1, -June 30, 19 Where Certified <br /> Operator Name 1.1 <br /> Plant Location 11 <br /> No. Units Served <br /> Plant Capacity <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: <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, and rules and regulations of the San Joaquin Local Health District. <br /> I- APPLICANT'S SIGNATURE X <br /> { <br /> FOR DEPARTMENT USE ONLY <br /> ,S Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &ReceivedREMIT <br /> uVy 31 <br /> .- BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> I FEE <br /> ,4 <br /> LESS <br /> PRORATION <br /> PLUS C{� <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I Receipt No- -Permit No. Issuance ate Mailed Delivered <br /> Re eiv by Date <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AYE, ;P.O.Box 2009 - STOCKTON,CA-95201 -- <br /> a c <br />