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r Applications Will Be Processed When Submitted Properly Completed. Be Sure-ToSign The Application. ld `pd fifo1• <br /> _ APPLICATION _ <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> ' SEPTAGE <br /> 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 /> y Business Name (DBA) A S&) el rW-5 ."77,2 A.) Address 1;,s— ,.s��..err.� y <br /> 1. a Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. / V 3 �7z Emergency Telephone No. <br /> Contractor Licence No. Zs,a I� <br /> Applicants Name (Print),FLd ®Q Title �S� Date <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 1111 Disposal Sites <br /> Description(Make/Yr., Color). a1. �� <br /> Serial No A� CAL. License No. CAL, Lic7nse Renewal No. <br /> Capacity !iM Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 1 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored �� r <br /> No. of Chemical Toilets Stored <br /> i 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location :W Test Date/Time tM` <br /> 4. A SANITATION PERMIT I� III' II <br /> Job Address/Location 43 J.t;- <br /> 116, C'ff G,0_1 �77aG/e< II <br /> Owner 5,:4N*_ z,5VU Address �M <br /> SEPTIC TANK 11CESSPOOL JV LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT C1 TEMPORARY NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS Fr July 1, -June 30, 19 ( <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PILANT For July 1, -June 30, 19 <br /> Operator Name 1I, Where Certified y <br /> Plant Location AA IM <br /> ' <br /> Plant Capacity No. Units Served IIM <br /> 7. ❑ LAUNDRY For July 1, -rune 30, 19 !I <br /> SIZE: ❑ Less Than 1,000 SgIFt., C3 More Than 1,000 Sq. Ft. <br /> I' ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> lel-ag,F) P17s OR22 -1 IbALP% OKA— <br /> i <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 Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> �y <br /> FOR DEPARTMENT USE ONLY <br /> Fee I&Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EIEACH ElJanuary Y&Received By January 31 ❑ Ju <br /> iy 7 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> r <br /> BASE' EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 0 ' <br /> FEE <br /> LESS A� i <br /> PRORATION I �I <br /> PLUS i. <br /> PENALTY II� <br /> OTHER Ili <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss ante Date Mailed Delivered <br /> T <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. ZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9. .., <br />