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Applications*111 Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transterable, Revocable;and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the,junsdictional area of the San Joaquin Local Health pistrict <br /> rn Business Name (DBA) A 54/ CL9d 220_'.- -e –,-70o4�,l _ Address <br /> i Owner Address <br /> 1Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No Emergency Telephone No..-- 4 "V <br /> Contractor Licence No. <br /> Applicants Name (Print) D 01 Title l Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information . Uj <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 /> t ic' <br /> Capacity " 'Gal.,Weights & Measures No. <br /> Equipment Parking Address0 �1 , <br /> F <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No, of Vehicles Stored <br /> No. of Chemical Toilets.Stored <br /> 3. 11 PERCOLATION— <br /> TEST�" " �' +.Ar:. <br /> R.S. or R.C.E.Name R.S. or R.C.E. No. <br /> TestLocation _ Test Date/Time <br /> 4. wl SANITATION PERMIT <br /> Job Address/Location's ti:_j �(J� �/� C TA <br /> Owner Address <br /> JK SEPTIC TANK ❑ CESSPOOL LEACHING FIELD X SEEPAGE PIT ❑ PACKAGE PLANT <br /> 19 PERMANENT O TEMPORARY ZI NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning!Lbcation(s) <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> r Where Certified <br /> Operator Name <br /> s •r77 tw�-� <br /> Plant Location <br /> Plant Capacity No.,Units Served <br /> r <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> . 1 ism A <br /> SIZE ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i <br /> ordinances, state laws, and rules and regulations of t San Joaquin Local Health District. ` <br /> APPLICANT'S SIGNATURE --k - <br /> F -FOR DEPARTMENT USE ONLY <br /> y vv�1a <br /> Fee Is Due: ❑ ANNUALLY- ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 "'`❑Uul 1 &Received 6 Jul <br /> • <br /> :'o F REMIT' <br /> BILLING REMITTANCE $ M <br /> AOUNT DUE CHECKED <br /> BASf EXPLANATION DATE F DATE 'r REMITTED <br /> 'AMOUNT <br /> % <br /> FEE <br /> LESS ..* <br /> PRORATIONPLUS <br /> i 5 <br /> a � - <br /> PENALTY Y <br /> OTHER ' <br /> �w <br /> e Y ' <br /> OTHER ' <br /> 33' rw <br /> �- <br /> Received by ate Receipt No. ermit No. Issuanc Date Mailed ,Delivered <br /> APPLICANT—RETURN ALL COPI S TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.F{AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201- <br /> .. <br />