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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatio Iereb m de o carry n bug�irLLIess in th Is Ictional area of the San Joaqui oc�l ealth District <br /> ,�Business Name (DBA) 1 ii e, C'kllA�' � Address �� 1 � AVe- <br /> a Owner 1 1✓h �'i FRl4�y Address <br /> Firm Partners, Addresses and T,plephone Numbers R <br /> aBusiness Telephone No. 823 r' Emergency Telephone No. <br /> Contractor Licence No. 2 X13 la <br /> L Applicants Name (Print) �+'+ C1�6+�t. Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information J <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. License No. CAL. Liocnae Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <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 <br /> Job Addres:a4I-ocation . 9 <br /> Owner �3 rN� k i'_Lm/�� Address 12 Sor�rte� '` <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD [ji SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 j Q5)C!U <br /> Type Construction Disposal Site pj® �- iN <br /> n pT 7o <br /> No. of Units Equipment Storage/Cleaning Location(s) c"3 <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 /> 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, as ules and regulations of than Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE.. _— <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION BILLING DUE CHECKED- <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ,✓ <br /> OTHER <br /> OTHER <br /> �5II47 9 o - d 1 <br /> Received by - - ate I Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 <br />