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c Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION j <br /> (For Non-Transferable, Revocable, and Suspendable) 5 <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carryon busines's in the jurisdictional area of the]San doaquin Local Health District <br /> OrBusiness Name (DBA) V•A.A��1_514 ,CJS ti3(,. Address J�5t1 •&bL (g'-,vb -STi4_0 <br /> 4 Owner 1 Address F <br /> Firm Partners, Addresses and Telephone Numbers 1 <br /> l a Business Telephone No. l�{ ®7 Emergency Telephone No. I <br /> Contractor Licence No. 7 S74� .34-3 — <br /> a <br /> L Applicants Name (Print) Title+5,S77iMA-f o 1C. Date J �� r <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1.'1 ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites i <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 /> 2.1 ❑ 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 R.S. or R.C.E. No: <br /> Test L Test Date/Time <br /> 4.1 <br /> ,I.ET SANITATION PERMIT <br /> Job Address/Location S4�.sx q_-k Lt�+0.TT�IC.S + -i'ICdl9C�1�i�/LP <br /> O0,wne.- � L Address * <br /> I1,SEPTIC TANK 11 CESSPOOL LEACHING FIELD C1 SEEPAGE PIT ❑ PACKAGE PLANT <br /> 2j7—PERMANENT ❑ TEMPORARY ❑ NEW ©REPAIR ❑ OTHER <br /> S." ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site i <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6.'i ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> 4 Operator Name t Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7,1❑ 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 , <br /> E <br /> I . I <br /> P <br /> I I hereby certify that I h pre ared this appI' t' n an that the work will be done in accordance with San Joaquin County <br /> l ordinances, state la a rules an egulati f th n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> I FOR DEPARTMENT",USE ONLY <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ 3uly 1 &Received By July 31 t. <br /> REMIT <br /> BASE - EXPLANATION BILLING REMITTANCE $t AMOUNT DUE CHECKED <br /> DATE 6 D TE REMITTED AMOUNT L_ <br /> I REE f + 7� 0,0 4 <br /> LESS <br /> ' PRORATIONPLUS <br /> � I PENALTY ,. i. - J <br /> OTHER <br /> t <br /> OTHER <br /> II _ 111 I <br /> 3 1-1 1 i <br /> ' Date <br /> Received by - a - Receipt No� Permit No. _ Iss ante Date ,ailed w Delivered <br /> r ? <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AY .Bo.2009 STOCKTON,CA 95201 <br />