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�.- _........ ..... .... . ...,........... ........ .. APPLICATION",�.�... ,. ....... ... ...,. ..... .r,..__....... <br /> (Trx/Non-Transterable, Revocable, and Suspendabll <br /> ENVIRONMENTAL HEALTH PERMIT SI PTAG� <br /> LIQUID WASTE <br /> Application is hereby madel�to carr on business in the jurisdictional area of the San Joa uin Local Health District <br /> Business Name (DBA) S vE, 1pl ryt Address C) ii 4 <br /> OwnerTKR Lt,. ... i�Y J r <br /> � Address -�.- -�� RAI. MRS- <br /> Firm Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. - �. ---- Emergency Telephone No. <br /> � �.� <br /> Contractor Licence No. �t__-SS' A-�, � '1, - - - <br /> Applicants Name(Print)_ �4- - ­_ . - Title .-_ s+ <br /> - —. Date Q <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �''{�S"Q L 012-2 <br /> For July 1, . __. June 30, 19 . Disposal Sites _ <br /> Description(Make/Yr., Color) <br /> Serial No. _--- -. -- ..--.- -- CAL. License No. _ .._.— - _ CAI. License Renewal No. - <br /> Capacity _ -__. . Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1,W June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored — T <br /> 3. PERCOLATIONN TEST <br /> R.S. or R.C.E. Name << 1�_ 0. R.S. or R.C.E. No. UA335 <br /> Test Location r ._ - '� "-Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner _-.._--_-� _ _ Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL © LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction _ _ _ __ Disposal Site <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 _-__ --_- <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 ap cation and that the work will be done in accord ce i San Joaquin County <br /> ordinances, state laws, apd rulesa d r ul s t th an Joaquin Local Health Di rict. <br /> APPLICANT'S SIGNATURE X !/ - AA ---- <br /> FOR DEPARTMENT USE ONLY <br /> Fee 1s Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH C3 January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> -t-- _. -- <br /> ` BILLING REMITTANCE <br /> REMIT <br /> BASE EXPLANATION 1AMOUNT DUE CHECKED <br /> X ,/ 1 DATE DATE EMITTED AMOUNT <br /> FEE / <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER.._... <br /> OTHER <br /> Received by Dale Receipl No- Permit No issuance Date Mailed Delivered <br /> r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE_P.O.Box 2009 STOCKTON,CA 95201 <br />