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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> �►—=�I` - .p APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUIB WASTE <br /> Applicatio Is hereby m de.to carry business int jurisdictional area of San Joa n Lo ealth District}f" <br /> y Business Name (D8A) iL�[r�J,fi�,tlE[.4 ea+�ST. p Address " ►�G� <br /> aOwner Address <br /> 0 Firm Partners, Addresses apo Telephone Numbers <br /> aBusiness Telephone No. ���� ,- Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Pri Title <br /> Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Calor) <br /> Serial No. CAL. License No. CAL. License Renewal No.--- �, <br /> Capacity Gal., Weights & Measures No. z <br /> Equipment Parking Address L <br /> 2, ❑ PUMPER YARD ?'t <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 LocationTest Date/Time <br /> 4. ❑ SANITATION PERMIIT'(�', �►1 r t - `^ " '` f <br /> Job Add(%/Locatiii <br /> Owners _ Address v <br /> ❑ SEPTIC TANK ❑ CES POOL TEACHING FIELD ---1!t-`SEEPAGE PIT.-,_0 PACKAGE PLANT <br /> W-PERMANENT ❑ TEMPORARY SNEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 5 <br /> Type Construction Disposal Site r <br /> No. of Units Equipment Storage/Cleaning Location(s)`_� <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Mme' Where Certified y <br /> Plant Location <br /> Plant Capacity No. Units Served F <br /> 7. ❑ LAUNDRY For July 1, -June 30,•19 <br /> SIZE: ❑ Less Than 1,000 Sq:,Ft.r 014Ore Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Ac s T.4tc. ,Lp L), Lt�aftl C1'.ce E � <br /> I hereby certify that I have prepared application a the,work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rul gulation ui oc ealth District. <br /> APPLICANT'S SIGNA <br /> FOR DEPARTMENT USE ONLY' <br /> , `S, L <br /> Fee Is Due: ❑ ANNUA'LLY ❑ PER PNIT ❑ PER SITE ❑ EACH 0 January 1 &Received By J uary 31 ❑ July 1 $ Received By July 31 <br /> BILLING RE ANCE 4 REMIT <br /> BASE EXPLANATION $ AMOUNT DUE CHECKED <br /> DATE ATE REMITTED s AMOUNT <br /> FEE41 <br /> { <br /> LESS <br /> �� <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Perrtlft o�.t Iss anc at Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PER 1601 E.HAZELT AVE.,P.O.Box 2009 STOCKTON,CA 95201— <br />