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� q 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 /> LIQUID WASTE o <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) T, 4P=k ISIM S�iroS Address PO '64OX <br /> i Owner . Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> -JContractor Licence No. `f'� 4 <br /> � <br /> Applicants Name (Print) Title E 5 T Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information ,4 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> i <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 k! <br /> R.S. or R.C.E. Name R.S. or R.C.E, No. <br /> Test Location Test Date/Time <br /> 4. 0 SANITATION PERMIT <br /> Jab Address/Location A $TGrE <br /> Owner �S� -++ -C - Address S'A�7G <br /> 29 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT '6 <br /> 9PERMANENT El TEMPORARY 13 NEW � REPAIR � OTHER Fl�rEQ f3�D '�l <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. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> j Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> Ir SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> I ❑ DRY CLEANING,Chemicals Used/Amount/Mo, <br /> 1 <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 rules and regulations of the Joaquit Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> _4 5- `ro err, 1`5 4iMn-°!l <br /> p- 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 /> REMIT <br /> . BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> t- DATE DATE REMITTED AMOUNT <br /> I <br /> FEEc <br /> t LESS +a Q <br /> t PHORATION <br /> PLUS <br /> PENALTY <br /> OTHER f�r� <br /> OTHER <br /> ( Received by Date Receipt No. - - Permit No Issuance Date Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON;CA 95201 r <br />