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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) SE°TAC <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application iso�hgreby made o cprryon business in the j risdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) R. W� S�,P4 ridAc ianOlPS Address 4, i; Cnr»n*dle Ave, <br /> a Owner Lane Tree Creek r/i�rd s Address�0, Bow S 97 <br /> J Firm Partners, Addresses and Telephone Numbers _,!T-q9- 4/1/ <br /> a. Business Telephone No. 943 `20 21 Emergency Telephone No. <br /> Contractor Licence No. <br /> �Applicants Name (Print) Ston 05h f A Title Date 6 7. 94 <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 /> 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 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored"! <br /> 3. 0 PERCOLATION <br /> R.S. or R.C.E. Name Tt.S.or R.C.E. No. <br /> Test Location SO 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 /> Homeowner or}i^ens�degen:ss'7r.�tra - .�rtctlmv,, j:"tcp,ti!ytot:nf110perfcrmnnceofthrrJorkfor which this permit isissued.Ishall ne;om to erscn <br /> in such manner as to become`3db;ect employ any <br /> Contractor's ! a - - , :.nn:c:: ctii, i!;L,in;he pertermance of the work for whi,, rmit isissued,I shall <br /> employ persons��., <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, ang rules and reg lati ri of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X �Qp <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE EMITTED AMOUNT DUE CHECKED <br /> !' AMOUNT <br /> 10 <br /> FEE G, l7� �t+l 2-7'Cp� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Rece' y Date Receipt N6. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />