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a Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> k. APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> v ENVIRONMENTAL HEALTH_ PERMIT <br /> A LIQUID WASTE <br /> Appl ication is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District 1 <br /> O Business Name (DBA) kh Address <br /> 4645 I;J id-reth Lane <br /> z Owner Address i <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a / Emergency Telephone No.-_ 7 <br /> M Business Telephone No. 9-31 �i _ — i <br /> Contractor Licence No. 133629 <br /> LApplicants Name {Print) Title - chzner Date 1 <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE s y �1 <br /> For July 1, June 30, 19 'Disposal Sites } <br /> Description(Make/Yr.,Color) ' 1, <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 <br /> i No. of Chemical Toilets Stored , y <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name t' R.S.or R.C.E:No. <br /> `"4 J. <br /> . <br /> Test Location Test Date/Time <br /> f 4. ❑ SANITATION PERMIT <br /> Job Address/Loca 'on <br /> OwnerAddress . <br /> ``` '` PACKAGE <br /> PLANT <br /> t ❑ SEPTIC TANK 1:1 CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT <br /> 13PERMANENT C1TEMPORARY ❑ NEW$ REPAIR E] OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30,'19 <br /> Type Construction Disposal Site a <br /> No. of Units q Equipment Storage/Cleaning Locations) <br /> _ <br /> 6. ❑PACKAGE TREATMENT PLANT For July 1, -June 30,1191-- <br /> t �. !>S W here Certified <br /> Operator Name a 4..4� <br /> .Plant Location <br /> l 'T I No::Units Served"-_ r <br /> Plant Capai~ity -, <br /> 7. ❑ LAUNDRY , For Ju'y 1, -June 30, 19 f <br /> k SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq'Ft. j x ? <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> - —J& <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, ansl rules d r lations t San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE_ X k <br /> I _ FOR-DEPARTMENT USE-ONLY- <br /> ' Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ` ❑ALACH ❑ January 1 &Received By January 31 . ❑ July 1 &Received By July 31 <br /> - , REMIT <br /> BILLING.� REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION.< - AMOUNT <br /> A _ - .� DATE_- .!DATE REMITTED <br /> FEE <br /> - <br /> PRORATION _ r - <br /> PLUS <br /> PENALTY <br /> _ .r. <br /> OTHER <br /> OTHER <br /> 07 <br /> Received by Date Receipt No. Permit No. I uance Date Mailed Delivered. <br /> APPLICANT—RETURN ALL COPIES'tO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20139 -STOCKTON,CA 9$201 <br />