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Appilcations Will Be Processed When Submitted Properly Completed. Be Su If <br /> To Sign The Application-1.4 <br /> /Y f <br /> APPLICATION <br /> ( Non-Transferable,Revocable,and Suspendat <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application Is hereby made to Carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,r Business Name (DBA) 6122 5e - Addresses i"� ��� /✓>./_��Q <br /> towner_-- 14 I_� amu,;�2 Address _ <br /> Y Firm Partners, Addresses and Telephone Numbers - <br /> Business Telephone No. '�✓'� ��*�� Emergency Telephone No. 'd <br /> Contractor Licence No. � C� 2 _ / r— <br /> �Applicants Name (Print) GL 2Title e-^^�`W�� Date �— <br /> Please check Applicable Category(1-7)and Fill in the Required Information W <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) J <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 Gal., Weights S Measures No. <br /> Equipment Parking Address _ Z <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 Test Date/Time <br /> 4. ❑ SANITATION PERMIT �y r '"7 <br /> Job Address/Location L d7— <br /> / ST�7f/n` in=L ��y AGC <br /> Address <br /> O,yw,�ner �CESn�aOL LEACHIN <br /> I SEPTIC TANK ❑ SPOG FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 11 TEMPORARY ❑ NEW, ❑-REPAIR ❑ OTHER /S. ❑ CHEMICAL TOILETS For,luly 1,-June 30, 19 VI <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 CapacityNo. Units Served <br /> 7. ❑ LAUNDRY For JUIy 1,-June 30, 1911 <br /> SIZE: ❑ Less Than 1,000 Sq: Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> c <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 and regulati ns of a San Joe n Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT 0.PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 d Received By July 31 <br /> REMIT <br /> BASE -, EXPLANATION BILLING EMITTA 5 AMOUNT OUE CHECKED <br /> DAT DA REMITTED AMOUNT <br /> FEE <br /> LESS !1 <br /> PRORATION •W t <br /> PLUS (;Ir <br /> PENALTY .•5`.' <br /> OTHER1 <br /> l 1 <br /> OTHER <br /> /a7S7 s134 <br /> Received by Date Receipt No. Permit No. I ulmcer Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bor 3009 STOCKTON,CA 95"1 <br />