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Applications Will Be Processed When Submitted Properly Completed. Be Sur To Sign Tire Application. `�/ ' <br /> _ APPLICATION <br /> Non-Transferable, Revocable,and Suspends ' <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of theJoaq Local HealthlD'istrict <br /> a Business Name (DBA ,� �., �i LGt> Q Address /,� ` �� l7 � <br /> aOwner , !' ' L G t' /'� Address <br /> 0 Firm Partners, Addresses andTelephone Numbers <br /> aBusiness Telephone No. 5y. S Emergency Telephone No. <br /> Contractor Licence No.. P <br /> Applicants Name SPrint) � L ^ Title a'�.A r7--4 z Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) W <br /> For July 1, June 30, 19 Disposal Sites. <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. rJ <br /> Capacity Gal.,Weights & Measures No. _ v <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 Location Jest Date/Time 2 L El �!><16�c� yrs• -- -°� <br /> 4. ❑ SANITATION PERMIT / /JQ <br /> Job Address/Location Ld ( 23` '9 r_0 <br /> Address <br /> LK SEPTIC TANK ❑ CESSPOOL I�CACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> Q PERMANENT Q TEMPORARY D NEW Q 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) �:4 <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: D.Less Than 1,000 Sq. Ft., Q More Than 1,000 Sq. Ft. - - <br /> ❑ 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 riiesand're lation of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1'ilt Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE E <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> ' � - DATE - DATE REMITTED yy AMOUNT <br /> FEE of <br /> LESS ' <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER y ( /�•, <br /> OTHER <br /> 3,;L �la� ht <br /> Received by Date Receipt No. Permit No. inufance base I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz ZIIOS STOCKTON,CA 95201 <br />