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Applications Will Be Processed When Submitted Properly Completed. Be Su To Sign The Application. 1 <br /> APPLICATION r �+ <br /> ( ion-Transferable,Revocable,and Suspendabl _ '� SEPTAG <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is he by made to carryon business in the jurisdictional area of the Sa aquin Local Health District <br /> Business Name (DBA) I AJIJ z: Address A! Cl, 3_-_.;xzz>!0z <br /> �S Owner .- ;4 , / l�ccAddress <br /> Firm Partners, Addresses and Telephone Numbers r <br /> Business Telephone No. `� Emergency Telephone Nd. <br /> j Contractor Licence No. <br /> L Applicants Name (Print) t'dL-L c-�� Title Date.—,I�' <br /> Please check Applicable Category(1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) l/ <br /> For July 1, June 39, 19 - Disposal Sites <br /> Description(Make/Yr.,Color) ' <br /> Serial No. CAL. License No. CAL. License Renewal No. C <br /> Capacity Gel.,Weights & Measures No. t <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 R.S.or R.C.E. No. <br /> Test Ocat on Test Date/Time <br /> 4. ITATION PERMIT / <br /> Job Address/Location <br /> Owner /z1-Cc�-e- Address <br /> ❑ SEPTIC TANK Q CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT •❑ TEMPORARY ❑ NEW '❑ REPAIR ❑ OTHER <br /> S. ❑ 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. 0 LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,OQQ Sq. Ft., 13 More Than 1,000 Sq. Ft. , <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I hays prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules andti 01 the Sen Joaquin Local Health District.lop <br /> /�APPLICANT'S SIGNATURE X 6e 1`�` V/ rte/ <br /> .. FOR DEPARTMENT USE ONLY <br /> ' Fee 1s Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Recerved By January 31 ❑ July 1 S Recerved By July 31 <br /> ..' REMIT <br /> 'BILLING REMITTANCE $ <br /> BASE DATE DATE REMITTED EXPLANATION - AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 'f t- Y V <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> (�- <br /> RecavOd by Date Receipt No. Perms N inuorme D to k Mailed Delnere0 <br /> APPLICANT—RETURN ALLCOPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20051 STOCKTON.CA 95201 <br />