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Applications Will Be Processed When,Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> J (For Non-Transierable, Revocable, and Suspendable) f <br /> ENVIRONMENTAL HEALTH PERMIT SEETAGE <br /> ter' [,MrIQUID WASTE <br /> Application is hereby mad to carry on business in the jurisdictional area of the Sa Joaquin Local Health District <br /> FBusiness Name OSA . � is ar 13 C/ /1OTC/1 <br /> (OSA) Address ri L_�^� <br /> aOwner d ,1. "L L G'r Address <br /> u Firm Partners, Addresses and:Telephone Numbers <br /> CL <br /> Business Telephone No. ! � � Emergency Telephone No. <br /> Contractor.Licence No. <br /> Applicants Name {Print) ter-!L,� Tc�GL �� Title !f*-- Bated - <br /> Please check Applicable-Category (1-7)and FIII 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., Color) <br /> Serial No. CAL..-License No:- CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address { <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 - µ <br /> No, of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. Q PERCOLATION TEST f - <br /> - � s <br /> R.S. or.R.C.E. Name R.S. or-R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT ` r <br /> Job Address/Location _ - 1!'ct�tJa 3 40. 1. <br /> AddrssOwner 1z), xe5 / AC- <br /> g5­, E"PTIC.TANK :[]-CESSPOOL Rk_fACHING FIELD ❑ SEEPAGE PIT. 0 PACKAGE PLANt <br /> ❑ PERMANENT 0 TEMPORARY ❑ NEW �- �❑ REPAIR. ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,7—June. 30, 19 l f' <br /> Type Construction Disposal Site ¢ <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> t <br /> 6. ❑ PACKAGE TREATMENT PLANT .For July 1, -June_30, 19 <br /> Operator Name Where Certified <br /> Plant Location Y _ <br /> Plant Capacity - - No Units Sery f . e <br /> 7. []..LAUNDRY For July 1, -June 30;A9 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft'. ❑ More Than -1,000Sq. Ft. <br /> DRY CLEANING, Chemicals Used./Amount/Mo y, <br /> tt <br /> hereby certify that I have prepared this ap cation and that the work will be done 1n:accordance with San Joaquin County <br /> ordinances,.state laws and rules and re Llatibbs of the San.Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE �r <br /> . 6 <br /> - FOR DEPARTMENT,USE ONLY". w <br /> Fee Is Due: ❑;ANNUALLY [],PER UNIT ❑-PFWSITE4' I ❑.EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ... - REMIT <br /> t ,BASE " EXPLANATION, -BILLING REMITTANCE S"". "^'�. AMOUNT DUE CHECKED I <br /> i DATE jDATE REMITTED i',G AMOUNT- <br /> i <br /> FEE <br /> LESS t � <br /> PRORATION - <br /> PLUS' - <br /> PENALTY f r <br /> OTHER <br /> r <br /> ;OTHER '� 1 <br /> A&a / <br /> Received by Date Receipt No:- PBrrpit No. IOuande Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEAMtT/SERVICES 1601 E.-HAZELTON AVS.,P.O..Box 2009 STOCKTON,CA 95201 - <br />