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Applications will Ne Processea when buomlaea Property Uomplelea. ne Sure so algn 1 ne Appucauon. <br /> APPLICATION <br /> ` (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> A licati n Is ere ade to car on bus ess in the jurisdictional area of the/�an Jo qwn Local Health District O <br /> hT,Business Name (DBA) /rf_ y �� -•-Address r� .�oxi�sa STK ' % �'ZO/ <br /> I- Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> Ow Business Telephone No. I" Emergency Telephone No. - <br /> a <br /> Contractor Licence No. <br /> Applicants Name (Print) �T�4.CJl�4 ��c�_C Tltl ST/.tA�P'7t,� Date <br /> r,Please check Applicable Category (1-7) and'Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1/11j <br /> For July 1, June 30, 19 Disposal Sites N <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. Licznse Renewal No. <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 <br /> L 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 <br /> L 4. SANITATION PERMIT <br /> Job Address/Location Oa99 W <br /> Owner � lG1-0e9,10-0 Addres,-s-� �fI <br /> 11 SEPTIC TANK 11R�I CESSPOOL 2-1EACHING FIELD SEEPAGE PIT 13 PACKAGE PLANT <br /> B- 11 �J� C <br /> PERMANENT ❑ TEMPORARY NEW L=1 REPAIR ❑ OTHER 'X <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> C <br /> Type Construction Disposal Site <br /> 6. 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 /> eae Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> L SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> 6. <br /> 1 hereby certify that I h ve prepared this application a that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws id rules apj regulati of t an J Squirt Local Health District. <br /> 6. APPLICANT'S SIGNATURE <br /> LFOR DEPARTMENT USE ONLY O` <br /> L Fee Is Due: IJANNUALLY ❑ PER UNIT ClPER SITE 11EACH ❑ January 1 &fft c v B January 31 ❑ July 1 &Received By July 31 <br /> BILLING RE TTANCE REMIT <br /> BASE EXPLANATIONBILLING <br /> ATE EMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> L LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r <br /> OTHER <br /> Received by Date Receipt No. Permit No. k asua a be a iled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bo[MIS STOCKTON.CA 95201 <br />