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s Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> c LIQUID WASTE . <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rBusiness Name (DBA) Address <br /> i i Owner_Ri4L" Address�84"'QftA-M J <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Emergency Telephone No. <br /> a Business Telephone,No. <br /> Contractor Licence No. <br /> Applicants Name {Print) A�10@4 AA SaA! J&- Title >K Date Ayra� — <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Q <br /> i For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL, License No. CAL. License Renewal No. V+ <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 t <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, 'Q SANITATION PERMIT 09 <br /> Job Address/Location ��S�t�O eAL, e� <br /> + Owner AL- L S G—E Address 85 Of.7 <br /> h <br /> 2 SEPTIC TANK 1:1 CESSPOOL [![-LEACHING FIELD 1:1SEEPAGE PIT ❑ PACKAGE PLANT <br /> I�PERMANENT ❑ TEMPORARY �EW ❑ REPAIR <br /> ❑ OTHER C <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> F 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 /> t Operator Name Where Certified . <br /> Plant Location <br /> 7. <br /> l Plant Capacity µ R No. Units Served <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 1a <br /> k <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 a nd regulations of the San Joaquin Lo al Health District. <br /> APPLICANT'S SIGNATURE X .� <br /> s <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> r REMIT <br /> RASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �j <br /> LESS <br /> PRORATION J , <br /> PLUS l h� ( [hff P( (O h <br /> PENALTY <br /> Z <br /> OTHER <br /> OTHER <br /> 3/03 CESS fC� - 1 _ <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />