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4. 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 SEPTAGE <br /> LIQUID WASTE <br /> Application i hereby ma a to carryon bu iness in th jurisdictional area of the S,an Joaquin Local Health Distr' t � L1 <br /> y Business Name BA) f o� Address j.6P �t-F 767 _ r <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL Business No.Telephone J-/0 <br /> a P �-� _ Emergency Telephone No. <br /> Contractor Licence No. x-a- <br /> �ApplicantsNam (Print) {Q Title �b Date 7— 7y <br /> ff <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 /> kDescription'(Make/Yr-., Color)_. <br /> Serial No. CAL. License No. CAL. Lic ,se Renewal No. <br /> Capacity Gal„ Weights & Measures No. E <br /> Equipment Parking Address 14 <br /> 2. ❑ PUMPER YARD <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 Larson Test Date/Time• ' s <br /> 4. I� SANITATION PERMIT <br /> Job Address/Lo <br /> 70 catio er -L ��- Address 31C 44J �C�- r �A- € <br /> V5 PTIC TANK ❑ CESSPOOL I�LEACHING FIELD LAS IT 11ACKAGE PLANT ; <br /> LwPERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 1'6t 14, 0 .l <br /> Type Construction Disposal Site �`� I t <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ✓ <br /> Operator Name- Where Certified ' <br /> Plant Location + ± <br /> Plant Capacity No. Units Served • '` `' <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 411 <br /> l <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> DRY CLEANING, Chemicals Used/Amount/Mo. Y4 <br /> I hereby certify that I have prepared this application and that the work wiwbe,do_ne in accordance with San Joaquin County i <br /> ordinances, state laws, and rules and regulations f the <br /> //San Joaquin!Local Health District`" 4 <br /> APPLICANT'S SIGNATURE X <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT bcpER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> V <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS ' �F J4.9.3J. •rF. g.. a .... <br /> PENALTY l <br /> OTHER I <br /> OTHER <br /> r <br /> Received by Date Receipt No. Permit No lavanc#Date Mailed lfel&wj <br /> APPLICANT—RETURN ALLCOPIESTO: NVIRONMENTAL HEALTH P MIT/SERVICES . 1601 E.HAZELTON AVE.,P.O.Box 2049 STOCKTON,CA 95201 <br /> - / �'1 �` z /1�D //-/4426/ <br />