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- -Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. Ai <br /> APPLICATION ' <br /> a - <br /> (For Non-Transferable, Revocable, and Suspendable) s' t <br /> # <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 Dystrict <br /> O Business Name (DBA) el Address- AV AO r <br /> z Owner V, Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) <br /> 6-92M> <br /> Title IZ- i Date <br /> Please check Applicable Category (1-7) and Fill In the Required Information <br /> 4 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) a <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) �1 <br /> Serial No. CAL. License No. CAL LicC 5e Renewal No. <br /> Capacity Gal.,Weights &Measures No. <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. (b <br /> Test Location Test Date/Time <br /> 4. 0 SANITATION PERMIT _ ~ <br /> Job Address/Location 3/5� .GJ: .n7/ /rr��J }✓ .7,4e AJ <br /> Owner Alt }f AJ E16 7`x r ChiMCMAddress <br /> JZ SEPTIC TANK ❑ CESSPOOL 0 LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW rel 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) <br /> 5. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location - <br /> Plant Capacity No. Units Served <br /> 4 7. ❑ LAUNDRY For July 1, -June 30, 19 k <br /> x SIZE: ❑ Less Than 1,000 Sq- Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 3 <br /> 1 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 regulations a Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> .. t <br /> �- FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑fPER UNIT ❑ PER SITE ❑ EACH ~'January 1 4L Received By January 31 ❑,July 1 &Received By July 31 <br /> BILLING - R MITTANCE $ REMIT ' <br /> BASE EXPLANATION PATE ATE ITTED AMOUNT DUE CHECKED `max 7 <br /> AMOUNT <br /> FEE b0 c: e `�� <br /> f'1 1 C 0 y <br /> LESS <br /> PRORATION_,, <br /> PLUSMr <br /> PENAL,TY w YJ <br /> OTHER <br /> OTHER <br /> Received'by Date Receipt No. Permit No. r _ Issuance Date Mailed . D ivered <br /> 281 <br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.�HAZELTON AYH.,P.O.Boer 2009 STOCKTON,CA 95 <br /> i <br />