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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 SEP7AGE <br /> LIQUID WASTE <br /> Application is hereby'made to carry on business in the jurisdictional area of the San Joaquin Local Health Distnck:._. <br /> rBusiness-Name (DBA) 'its, 112- ; 4'-'�" , , l Address <br /> u, <br /> aOwners �; ° 1�� -it Address <br /> Firm Partners, Addresses and Telepho a Numbers h <br /> a Business Telephone No. �`- r^ 1 Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> i <br /> L Applicants Name (Print) Ch 't ' � � �`� � Title � '• - Date _ { <br /> Please check Applicable Category (1-7)and Fill In the Required Information t_I`(;� :: t€ �;;':�`.��� �F6 % E <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) • Or0 41 C*ockton, Czjf. 95205 <br /> For July 1, June 30, 19 Disposal Sites Ph,463-3209 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. s <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 I <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 r <br /> 4. 91 SANITATION PERMIT 'I <br /> Job Address/Location <br /> Owner :;4 1� C t; t Address ; ,0? <br /> IPk SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT _ t <br /> PERMANENT ❑ TEMPORARY . NEW - -REPAIR a -0'OTHERP <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30,,19 " ? ' <br /> itDisposal , s <br /> Type Construction SiteNo. of Units Equipment Storage/Cleaning Location(s) I' <br /> 6. ❑.PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t F'I <br /> Operator Name .I 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, and rules and regulations of the San Joaquin Lbcal Health District. <br /> APPLICANT'S SIGNATURE X ..' r <br /> s V.0 n` y•f <br /> 'I 5.4�?, ,3"u� E^[s(S�i uGLO 'S <br /> _ ! yi �_A v �- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY 0❑ PER UNIT ❑ PER SITE Cl EACH ❑ January 1&Received By January-31 ❑ July I &Received By July 31 <br /> _ <br /> REMIT <br /> BILLING REMITTANCE $ <br /> AMOUNT DUE CHECKED <br /> BASE EXPLANATION PATE PATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS . _ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER i <br />