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Applications Will Be Processed When Submitted Properly Completed. BeSureTo sign IneAppucallon. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEETAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE F <br /> Applicatto r b m e to carry b si ess in the jur dictional area of the S�I o�aquin Ith District <br /> H Business Name DBA) ).TeS 39ilmoe 3� 2 Address <br /> i Owner 1+^1 RG��� Address <br /> a <br /> Firm Partners, Addresses and Telene Numbers <br /> p�g <br /> CL Business Telephone No. 2 3 g Emergency Telephone No. x <br /> a <br /> �Contractor Licence No. <br /> L Applicants Name (Print) Title Bate Q <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) t <br /> For July 1, June 30, 19 Disposal Sites J? <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Lic ae Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD f <br /> For July 1, June 30, 19 <br /> f <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERM'It <br /> 7; �DFFA7i 134 VD <br /> Job Addres ocation `7 6-71 <br /> Owner 'e'y G 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 Locations} /q01� 4 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <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 and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r wand regulations of San,Jy�quin Local Health District. <br /> APPLICANT'S SIGNATURE X ' rp�� I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jwy 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> Q DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Date Receipt No. Permit No. I uance ate Mailed Delivered <br /> Received by <br /> AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16D1 E.HAZELTON <br />