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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> fT APPLICATION <br /> (For Non-Transferable;Revocable;and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL_ HEALTH PERMIT Y. <br /> LIQUID WASTE <br /> f Application is hereby made to carry on business in the jurisdictional area of the-San Joaquin Local Health District <br /> t F Business Name (DBA) A541 G/o.c�sr-2���o.1J Address_/-i.S�• _7"1 >� -5 <br /> z Owner Address -- - <br /> a _ <br /> J Firm Partners,Addresses and Telephone Numbers <br /> I a Business Telephone No.; -7 Emergency Telephone No., - <br /> Contractor Licence No. l <br /> Applicants Name (Print) ALX Li lop Title ��G✓ � Date f�� <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 /> Description(Make/Yr., Color)* <br /> Serial No. CAL. License No.` CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. 4 <br /> Equipment Parking Address.. <br /> 2. ❑ PUMPER YARD i r <br /> For July 1, June 30, 19 ` _ <br /> No. of Vehicles Stored <br /> No, of Chemical Toilets Stored <br /> 3. ❑-PERCOLATION TESTR.S. or R.C.E. Name ' a I R-S_or R.C.E. No. <br /> Test Location -..Test Date/Time <br /> 4. C4 SANITATION PERMIT <br /> Job Address/Location Le 7 S' G' eC <br /> Owner dress <br /> ❑ SEPTIC TANK ❑ CESSPOOL. j LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ` ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July i,-_June 30, 19 <br /> Type Construction Disposal Site (. ; <br /> No. of Units Equipment Storage/Cleaning Location(s) *� r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> ` Plant Location <br /> w }: <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For Julil,--'June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq.-Ft., More Than„L,000-Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ~� <br /> 3 •r. 7 �v <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 regulatl`ns of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X s � <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH .❑ January 1 &Received By January 31 ❑ July f &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> GATE DATE REMITTEp - AMOUNT <br /> FEE 5 - - rl + c •- - - - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - t <br /> OTHER <br /> r <br /> OTHER ' <br /> Received by Date Receipt No. Permit No. Issubrice Vate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O:Box 2009 STOCKTON,CA 95201 <br />