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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) S) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> s Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> I _ <br /> I F Business Name (DBA) T>+ Address r&B@ X 1!4� a57;ie Al 9 rA.ig <br /> a Owner Address <br /> 3 Firm Partners, Addresses and Telephone Numbers <br /> Q. Business Telephone No. 41�4,lo—9G0-7 Emergency Telephone No. <br /> Contractor Licence No. 3 <br /> Applicants Name (Print) D D Title 6 sr/x"A777L Date V74-- <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <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. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> ' For July 1, June 30, 19 <br /> No. of Vehicles Stored e <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 /> x 4. X SANITATION PERMIT <br /> Job Address/Location �,/7'$ S + 1 <br /> Owner L A'Air, 9 CO. Address S A5 , A�A S7—A-4•1/ <br /> I� SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ® SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑;:OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> i 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 /> } Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,,Chemicals Used/Amount/Mo. <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 /> r ordinances, state laws,and rules and re3ulationytTlthean Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> • i <br /> a <br /> I FOR DEPARTMENT USE ONLY <br /> f Fee Is Due: ❑ ANNUALLY © PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT , <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE SC4 <br /> C7/ 3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 1 OTHER <br /> t <br /> { OTHER <br /> _7 9 9 �- i <br /> Received by -Date Receipt No. - Permit No. - Issuance Date Mailed Bred <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/�5� A. 1601 E.HAZELTON AVE.„P%8qx 2009 5 OCKTO ,CA 952Q1 <br />