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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The cation. <br /> APPLICATION <br /> ATION ti <br /> - (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL_ HEALTH PERMIT <br /> LIOUI]WASTE <br /> Application is hereby made to carry on business'i, the jurisdictional area of the n Joaquin Local Health District <br /> yBusiness Name (IBA) L <br /> aOwner.1-9, AL-r Address <br /> J Firm Partners, Addresses a d Telephone Numbers <br /> IL <br /> Business Teleph 40-Na .: Emergency Telephone No.. <br /> Contractor Licence No. ' <br /> ,L <br /> Applicants Name Print <br /> PP '(,Print))- Title. Date y _ <br /> Please check Applicable Category (1-7)'and Fill in the Required Information f <br /> �❑"PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For JLiy 1, ----Il June 3fl, 19 Disposal Sites - ----- �•. . <br /> Description(Make/Yr., Color) <br /> l Serial No. �N CAL. License No. CAL, License Renewal No. <br /> C5-0ac'ity`-­4��'�-^�"�~Gal7Weights=&MeasuresNo.=-..i—` <br /> ._` : . ,.. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1,7-:jJune 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 11 Test Date/Time ; r <br /> 4. ❑ SANITATION PERMIT <br /> I r r <br /> i Job Address/Location / © cJ C <br /> Owner 'T21n a: 1 Sjj �}A"LC- Address01 <br /> { r <br /> ❑ SEPTIC TANI(I ❑ CESSPOOL; E ,LEACHING.FIELC SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY-3❑ 'NEW. '�'t fi REPAIR ❑ OTHER <br /> i ..< <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 /> .6. ❑ PACKAGEiTREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name 0 ' - -t• �' <br /> Where Certified <br /> 4. <br /> .Plant Location <br /> I Plant Capacityy <br /> No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30; 19 ,E <br /> �,'. <br /> SIZE: ❑ Less han 1,000 Sq. Ft.,, 13 More Than 1,000 Sq. Ft. 4-- <br /> - - ' <br /> ❑ DRY CLEANING, Chemicals Used%Amount/Mo. <br /> k <br />, 1. 'i ... .r-•leF .,.'.. - .. -. - --5- �j <br /> -I hereb certify„thaQ have prepared this application a that the work will be done in accordance with San Joaquin County <br /> tic <br /> state laws�hd rules and regulations o the S Joaquin Local Healfh�District, <br /> APPLICANT'S SIGNATURE <br /> - _ <br /> FOR DEPARTMENT USE-ONi Y . M <br /> Fee Is Due: I7 ANNUALLY ❑ PER UNIT. ❑ PER SITE ❑ EACH •❑ January 1 &Received Ry January 31 0•-Juty 1 &,Received By July'31 <br /> t t BILLING REMITTANCE” $ REMIT <br /> BASE EXPLANATION �, AMOUNT.DUE CHECKED <br /> �'" -` •'- -GATE-- DATEs- REMITTED AMOUNT - - <br /> FEE <br /> LESS = <br /> PRORATION <br /> PLUS j <br /> PENALTY. .. -.- .-w /--.4.-,.. rt•x...�.. ...i .."`I . ... <br /> OTHER <br /> } OTHER <br /> AA i <br /> Recerved.by Q� Date Receipt No. Permit No. i' Issuance-D a Ma11ed Delivered <br /> YY .,� .4, ,;, 4 r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601-E.HAZELTON AVE.,P.O.Box 2609 STOCKTON,CA 95201 <br />