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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. j <br /> ' APPLICATION <br /> ,. (For Non-Transierable, Revocable, and Suspendable) <br /> .• ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry own ,.business in the jurisdictional area of the San Joaquin Local Health District <br /> 0 Business Na mee (DBA) ��ntI��e AAe=.-s � AIO - Address <br /> z Owner ��/re�.�A s�Gd� Address— � <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �-�—3�0 - Emergency Telephone No. <br /> Contractor Licence No. Cz – <br /> L Applicants Name (PTitle 'G/f�.. 4J'LcZLIM Date 2-- <br /> Please <br /> Please check Applicable Category (1-7)and Fill in the Required Information ' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) i <br /> For Jily 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 /> i <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 Location Test Date/Time –) <br /> 4. SANITATION PERMIT bi <br /> Job Address/ ation =T 3. r� '� �'` �� 01 <br /> Owner Address r <br /> OSEPTIC TANK ❑ C&SPOOLLEACHING FIELDSEEPAGE PIT El PACKAGE PLANT <br /> 17 PERMANENT ❑ TEMPORARY NEW ❑ REPAIR 13 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br /> Operator Name Where Certified xj <br /> Plant Location <br /> PIanYCapacity <br /> No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 r <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> hereby certify that I have prepared this application and that the work will be nI( accordance with San Joaquin County <br /> ordinances, state laws, ante nd regulations of the San Joaqur, Local Health istrict. <br /> APPLICANT'S SIGNATURE X <br /> 38 <br /> FOR Dmcff <br /> USE ONLY <br /> `• Fee IS Due: El ANNUALLY ❑ PER UNIT Y El PIER SIT ❑ January 1 &Received By January 31 ❑ Jufy 1 &Received By July 31 <br /> REMIT <br /> i BASE EXPLANATION L REMITTANCE $ AMOUNT DUE CHECKED <br /> E DATE REWTTED AMOUNT <br /> D <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ;5 OTHER <br /> a - <br /> E� OTHER <br /> q` a <br /> Received by lbate Receipt NO PermNit o. Issuance Date ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AV .0.Box 209 STOCKTON,CA 95201aRn. <br />