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Applications Wlll Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r — <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application i repy mad o carry on b ess i the j sdi onal area of the Jo um Local Health Dist t <br /> F Business Name (D ) L 1 1 Address <br /> z Owner — <br /> a Address <br /> Firm Partners, Addresses andel Telephone Numbers <br /> a Business Telephone No. MA(91r)05 <br /> _ Emergency Telephone No. <br /> -j Contractor Licence No. - $z2 <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill In the Required Information (1 ) <br />% 1.,E PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1� u June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> - <br /> Serial No. 'CAL.License•No. CAL. License Renewal No. <br /> Capacity -GaIPWeights &Me_asures No. <br /> Equipment Parking Address C a <br /> 2. 11 PUMPER YARD <br /> For July 1, June 30, 19 . r <br /> No. of Vehicles Stored*— + <br /> No. of Chemical Toilets Stored <br /> 3. 11❑ PERCOLATION TEST A <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Dation Test Date/Time <br /> 4. L'J SANITATION PERMIT # <br /> e �] <br /> Job Address/ ocati�AtZ(.E.L.a.���.�.�• �`. <br /> �,,,,,,O,,,,,,���ww�r Address ] " I Y33 <br /> EPTIC TA ❑ CESSPOOL EEACHING FIELD �❑ �OPACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW t,ta REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 4N 4— + <br /> Type Construction Disposal Site F _ <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> _ Where Certified <br /> Plant Location' s <br /> Plant Capacity No. Units Served I <br /> 7. ❑ 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 /> :I <br /> I hereby certify that I have prepared this applicatip and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rut and regulation 't San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE Xt-T'`. <br /> t / t . -iia._ <br /> `. FOR DEPARTMENT USE ONLY <br /> Fee e Is Due: ElANNUALLY ElPER UNIT ❑ PER SITE.i-10 EACH_❑ January 1 &Received By January 31 EJJuly 1 &Rece d By Jufy 31 <br /> } <br /> B!L_LING>. W REMITTANCE $ MIT <br /> RASE EXPLANATION j1 j;4 'fes. AMOUNT DUE CKED <br /> PATE W+&DATE REMITTED <br /> OUNT <br /> FEE { l� 5r- r 4 fr +�° <br /> LESS 1 lam` �A <br /> PRORATION <br /> ' PLUS_..._— <br /> PENALTY # - <br /> OTHER <br /> OTHER <br /> s <br /> L16 ;Vl- <br /> Received by Date Receipt No, Permit No. Issuanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20D9 STOCKTON,CA 95201 <br /> J <br />