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ApplicationsWill 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 /> Application is hereby made to carry on-business in the jurisdictional area of the Say Paquin Local Health District <br /> rBusiness Name (DBA) cT4tL) Address • d• { 'e T<-A <br /> a Owner 4 ,2 Z G L� Address <br /> L) Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) r C-cam 2 Title C .i Date <br /> Please check Applicable Category i <br /> Pp g ry (1-7) and Fill in the Required Information � <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> 4 <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights R Measures No. - <br /> Equipment Parking Address <br /> 2. 13 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 /> Testi cation Test Date/Time r� <br /> 4. Isd SANITATION PERMIT <br /> Job Address/Location 15 A4.2--c-- 4, <br /> � <br /> Own � - - = Address �( �� <br /> 1/� <br /> GR <br /> � SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 'B'REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site �61 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 f <br /> Operator NameWhere.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 /> a � <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 anVir2aul.9tions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> . FOR DEPARTMENT USE ONLY <br /> 11r�rt <br /> Fee Is Due: ANNUALLY L.7-PER UNIT ❑ PER SITE _ ❑ EACH ❑ January 1 &Received By Jaquary 31 -❑ July 1 &Received By July 31 .� <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT y-1 <br /> DATE DATE REMITTED AMOUNT DUE CHECKED 5I? <br /> AMOUNT <br /> FEE U <br /> LESS <br /> PRORATION <br /> PLUS �- <br /> -PENALTY . .-. ._ .- <br /> OTHER <br /> OTHER I <br /> k <br /> Received by Date Receipt No. Permit No. Iss Vance Date iuiailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2069 STOCKTON,CA 952060 <br />