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- 'Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION - <br /> r (For Non-Transferable, Revocable,and Suspendable) ` <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE , <br /> LIQUID WASTE <br /> Application is hereby m de to carryon business in the jurisdictional area of the San Joaquin Local Health aDi�trict <br /> OF Business Name (DBA) b- � F 11-3 M� t� L".._ Address <br /> aOwner. 7Zt)k 'M `Q I . Address <br /> j Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No.1-4-2—GLW z - „ <br /> Contractor Licence No. <br /> L Applicants Name (Print) <� Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information �- 9 <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. Licznse,Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> ,Equ.ipment Parking Address. _ <br /> 2. ❑ PUMPER YARD <br /> For'Jul"I" June 30, 19 <br /> No'of Vehicles Stored <br /> No.'of Chemical Toilets Stored4 _ `1v� ' ' <br /> 3. El PERCOLATION TEST ;~ <br /> .R.S'or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location T Test Date/Time-' <br /> 4. ❑ SANITATION PERMIT <br /> Job'.Address/Location L+3 Lo 91 - <br /> Owner _&i'vh•- Address <br /> ❑ SEPTIC T NK ❑ CESSPOOL--- ` LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENTS ❑ TEMPORARY NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS `For'July 1, June 30, 19 <br /> Type Construction Disposal Site # i <br /> t. .. <br /> No.�of Units Equipment Storage/Cleaning Location(s) <br /> 6- ❑ PACKAGE TREATMENT PLANT IFor-July 1, -June 30, 19 <br /> Operator Name Where Certified 4 <br /> Plant Location ' 7 <br /> Plant Capacity No.Units Served - <br /> 7. ❑ LAUNDRY For July 1, -June 30_19 T £ <br /> SIZE: ❑ Less Than 1,000 Sq.-Ft., 0 More Than 1,000 5q. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount Mo. ---� <br /> 1 t t d el eye <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, d rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUREX O - 7` C f��' By <br /> ' .W# FOR DEPARTMENT USE ONLY <br /> ff <br /> Fee-Is-Due: ❑ ANNUALLY's ❑ PER-UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> EXPL REMITTANCE $ <br /> j_ s ✓ i BASE E7(PLPL AIVATION D 3 AMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FEES �' hwc Uk.. --L a�- <br /> tiK LESS `t] <br /> PRORATION 2 f — f 0 ¢I rtI h.• g <br /> - PLUS J <br /> 7 PENALTY . 3 .. Y� v - rYl (�•� <br /> H <br /> OTHER <br /> OTHER�,�-�.--"_. ,..r--- �.-.— ., .: .--�.�......,. -- .._ -ter.. _•�,�... _ - -. ,.>. <br /> ;�- .� � .. �,. . �� �. :�` -, a ,_0.n.� <br /> Received'by ate I Receipt No. Permit No. issuance Date Mailed Dehvered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E..HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 �y <br />