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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION K1 -7-0- 2983 ' 63 <br /> 9 (For Non-Transferable, Revocable, and Suspendable) <br /> / ENVIRONMENTAL HEALTH PERMIT zr_ - 01 <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) �� U �_��w�L Address _7599 U 0^�TZ_0AJ2 4_X2 l=:V'T_ l <br /> aOwner Address r3,3-7 Co <br /> Firm Partners, Addresses and Telephone Numbers M NA <br /> It, Business Telephone No. �� - ��S Z2�� P Emergency Telephone No. <br /> Contractor Licence No. <br /> �Applicants Name (Print) �fl A 1 - Title S�� 1aW t Date 7 4`02> <br /> Please check Applicable Category (1-7) and Fill in the Required Inco ation <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 Gat.,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. �§ PERCOLATION TEST <br /> R.S.or R.C.E. Name On," I"tnt47L-- R.S. or R.C.E. No. 2 1255 <br /> Test Location — 15 liAr wl- — Test Date/Time � , f x)t '� Dz ��I 21AtJ <br /> 4. ❑ SANITATION PERMIT (.P <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 U d/ ouht/Mo <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. <br /> APPLICANT'S SIGNATURE X _ Title �7f, C`1 Date -1r 7/ <br /> F PARTMENT 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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE / <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> l <br /> e y Date Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />