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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 /> 0 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> c <br /> Business Name <br /> �? �� <br /> N f fA�� ��`! _ Ads <br /> dres5 - a <br /> a'Owner ,Address . -- <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. - 'Emergency Telephone No: <br /> -J Contractor Licence No. S' <br /> L Applicants Name (Print) D <br /> „ Trtle <br /> ate <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> ` For July 1, _ -June 30, 19­ - Disposal Sites " '' <br /> 1 <br /> Description(Make/Yr., Color) <br /> Serial No: CAL. License No. CAL. License Renewal No. <br /> Capacity " " Gal.,Weights & Measures No. <br /> G Equipment-Parking Address <br /> 2. ❑ PUMPER YARD ` <br /> rk . <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. rF�l SANITATION PERMIT <br /> Job Addres Location <br /> Owner Address '�� i <br /> JM SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD 11SEEPAGE PIT ❑ PACKAGE PLANT' " <br /> 11PERMANENT El TEMPORARY-. ❑ NEW 19 REPAIR ' Cl OTHER R <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Disposal Site Type Construction � - - .[ <br /> No. of U60S Equipment Storage/Cleaning Location(s) - <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> 'Operator Name � �- <br /> "Where Certified <br /> Plant Location 4t ` <br /> ... , ♦- _ ._. is -wii. •-_. . Y .. '.-: 'v ^ - .. <br /> Plana Capacity No. Units Served <br /> ..a ,x,. _ <br /> 7. ❑ LAUNDRY- For'July i, -June 30, 19 � �• � +� _.,4- <br /> - <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ; <br /> DRY CLEANING, Chemicals Used/Amount/Mo. �,, <br /> I hereby certity'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 of the San oaquin Local Health District. <br /> `APPLICANT'S SIGNATURE X } - <br /> FOR DEPARTMENT,USE ONLY <br /> Fee Is Due: ❑_ANNUALLY D PER UNIT ❑ PER SITE ❑ EACH •❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 a <br /> REMIT <br /> BASE EXPLANATION BELLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE - REMITTED AMOUNT <br /> r s�FEE S - .t-. .. l .... <br /> LESS <br /> PRORATION - <br /> PLUS ` <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER - <br /> 8 <br /> -------------- <br /> Received"by Date' ! .Receipt No. Permit No. ass ce D e Mailed Delivered r <br /> APPLICANT—RETURN ALL COPIES TO: 4 ENVIRONMENTAi'HEALTH PERMITISERVICES 1601 E.HA TON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> ! m <br />