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APPLICATION <br />(For Non-Transterble. Reviicable, and Suspendable) <br />ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br />LIQUID WASTE Z_SOD — V <br />Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br />Business Name (DBA) V. A. Etigle.l..5. Ale SQX1S eV 45e P /4 1 ,g-b Address <br />Owner fl7 4. Pi•Voietreal...S./___ Address <br />Firm Partners. Addresses and Telephone Numbers _ <br />Business Telephone NO. - e) 7 <br />Contractor Licence U. <br />Applicants Name (Print) i 0 0 Title 772/e- Odle igri/317.7 <br />No <br /> Emergency Telephone No <br />Please check Applicable Category (1-7) and Fill In the Required triton-nation <br />1. 0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />For July 1. June 30, 19 Disposal Sites <br />Description (Make/Yr., Color) <br />CAL. Licc.13e Renewal No Serial No. CAL. License No. <br />Capacity Gal., Weights & Measures No. <br />Equipment Parking Address <br />2. 0 PUMPER YARD <br />For July 1 - June 30, 19 <br />No. of Vehicles Stored <br /> Test Date/Time <br />SANITATION PERMIT <br />Job Address/Loc.ation -rh`r, V e 3> Xv- ; <br />Owner dVA <br />0 SEPTIC TANK 0 CESSPOOL NI' LEACHING <br />PI PERMANENT 0 TEMPORARY 0 NEW <br />0 CHEMICAL TOILETS For July 1. - June 30. 19 <br />No. of Chemical Toilets Stored <br />3. 0 PERCOLATION TEST <br />R.S. or R.C.E. Name <br />TeWrocation <br />rti <br />R.S. or R.C.E. No. <br />A). ev.i7 Pd. <br /> Address -71/4 P6r2-TA///1/., -5-7"oc,e_7oJ <br />FIELD El SEEPAGE PIT 0 PACKAGE PLANT <br /> <br />0 REPAIR 51 OTHER uo, <br />Type Construction Disposal Site <br />NO of Units Equipment Storage/Cleaning Location(s) <br /> <br />0 PACKAGE TREATMENT PLANT For July 1, - June 30. 19 <br />Operator Name Where Certified <br />Plant Location <br />Plant Capacity <br /> No. Units Served <br />0 LAUNDRY For July 1, - June 30, 19 <br />SIZE: 0 Less Than 1,000 Sq. Ft., 0 More Than 1.000 Sq Ft. <br />0 DRY CLEANING, Chemicals Used/Amount/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, and rules arid regulatioa of the San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X <br />FOR DEPARTMENT USE ONLY <br />Fee is Due! 0 ANNUALLY 0 PER UNIT 0 PER SIT E EAGH 0 January 1 8. hieceried B Jarwary 0 Jut), & neceiveo By July 31 <br />bASE EXPLANATION BILLING NEW I I ANCE <br />IIATE DATE REMITTED Amouhi - DUE <br />At <br />REMIT <br />C,I-1ECK E0 <br />AMOUNT <br />FEE <br />...0•1•11111meme <br />LESS <br />PRORATION <br />•• PLUS <br />PSNALTY <br />OTHER <br />Or HEI, <br />CVO 6 cl 19 — <br />Heceived by ()air: F1.7,:i!T1 No Perrntt No <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />— <br />5?/5/? <br />Is 1ance .arc Maicd <br />1901 E. HAZELTON AVE., PO. Box 20D9 STO KTON, CA 9520 <br />dPAX/