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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> �4_1 /o/yDO l (ForNon-Transferable, Revocable, and Suspendable) $EPTAGE" 1 <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> 00 LIQUID WASTE .� <br /> Applica on is hereby m de to carry on busine s in the jurksdictional area ofdhe San Joaquin Local Health District 1 <br /> Business Name (DBA) �- C)E-Address <br /> aOwner L.^ E+ L� , . Address. 1 .. <br /> Firm Partners, Addresses y ephone Numbers .i <br /> 0 Emergency Telephone No. <br /> IL Business.-Telephone No _.. . <br /> Contractor Licence No _ <br /> LApplicants Narrie (Prmt) -� --'. 'Title ate- <br /> Please check Applicable Category (1-7) and Fill in the Required'Information t,,4 „ - . �, a "• <br /> Y f1: ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,7~ June 34, 19 -=_ Disposal Sites- - - <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capa1 ity'" " 1- G"al?Weights-&-Measures-No, <br /> Equipment Parking Address <br /> r <br /> .2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> .No. of Vehicle.........s <br /> l S- ored <br /> No. of Chemical Toilets Stored t <br /> 3. ❑ PERCOLATION TEST r r, <br /> r R:S.'ar R.0..E.No. I' ~ <br /> R.S.or R.C.E. Name <br /> Test Location. - x� jest,-Dile/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location (' <br /> Owner Address <br /> ❑ SEPTIC TANK C ;SPOOL---' LEACHING FIELD CXSEEPAGE PdT ❑.PACKAGE PLANT' I <br /> r �� 1:1 OTHER <br /> 11 PERMANENT ❑ TEMPORARY NEW REPAIR - <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 34, 19 b t <br /> Type Construction + Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> j <br /> _ - <br /> 6:' t❑ PACKAGE TREATMENT PLANT For July 1,� June 30,19 <br /> Operator Name f Where Certified <br /> r 1 i <br /> Plant Location <br /> No. Units Served <br /> iPlant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June;30, 19 <br /> SIZE: ❑ Less Than 1`000 Sq. Ft., ❑ More Than 1,000 Sq.-Ft. t <br /> ❑ DRY CLEANING,Chemicals UsedlAmount/Mo. <br /> it <br /> r <br /> 1 l hereby c I have prepared this applicatio and that the work wi(l be done in accordance-with San Joaquin County f <br /> ordinances, laws rul sand regul tions of a San oaquin Local Health District. <br /> !APPLICANT'S SIGNATURE ] _ i{: -II— t <br /> t FOR DEPARTMENT USE ONLY <br /> i <br /> Fee IS DUE: E3 ANNUALLY PER UNIT ❑ PER SITE ❑ EACH., ry❑ Janua1 &Fipceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT'':! <br /> t. 3 BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION " , -DATE- - DATE• 3REMITTED.-' AMOUNT. ff <br /> } FEE �, s <br /> _ � 3 <br /> ,y <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> - � . . . <br /> �. OTHER <br /> OTHER <br /> 3 <br /> �— issuance Date M "ed Deliv, <br /> Received by Date Receipt No:. r S Permit No {� <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES "1601 E.HA2ELTON AY f�•Q20 9 TOC CA 9 Ot <br />