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>. 'Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 1J <br /> s APPLICATION J <br /> (For Non-Transierable, Revocable,and Suspendable) I <br /> ENVIRONMENTAL. HEALTH PERMIT SEPTAG� I <br /> LIQUID WASTE 6V <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District d <br /> nBusiness a (DBA) Address <br /> Q Owner �N� t9VF,L Address sa_ n �el` �s�+ <br /> Firm Partners, Addresses and Telephone Numbers _S99- 3 D <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> 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) i� <br /> For July 1, June 30, 19 Disposal Sites r.; <br /> Description(Make/Yr., Color) (r� <br /> Serial No. CAL. License No. CAL. License Renewal No. —+ <br /> Capacity Gal., Weights & Measures No. j <br /> Equipment Parking Address �I <br /> 2. ❑ 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. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. &SANITATION PERMIT �S <br /> Job Addr s/Location � —_ __ ,rr <br /> Owner IN_k)0FtLL \J. �8.�1 VS-1 Address 1-11535 �so . nhler <br /> Pr SEPTIC TANK ❑ CESSPOOL ',EJ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 <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 /> hereby certify that I have pr this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a s an regulations of th an Joaquin L al Health District. <br /> APPLICANT'S SIGNATURE X <br /> M <br /> FOR DEPARTMENT USE ONLY I / <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT rX PER SITE ❑ EACH ❑ ianuaryjy1&te6e1vec1 By January 31 ❑ July 1 &Received By Juky 31. <br /> REMIT <br /> BILLING REMI TANCE $. <br /> BASE EXPLANATION DATE T REMITTED AMOUNTDUE CHECKED <br /> - AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - - <br /> PLUS <br /> PENALTY - - - <br /> 1 <br /> OTHER <br /> OTHER <br /> 779--7t._ <br /> Received by y Date Receipt No. Permit No. Issuance Data Mailed D ivered <br /> k APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601E HAZELTON AVE.,P.O.Bo=2009 5 CKTON,C - <br />