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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,fand Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio�j is hereby made to carry on business in the jurisdi tional area of the San Joaquin Local Health D, trict. <br /> yBusiness Name (DBA)_L,4 ta+4YP-- Q o 7's -C 7' If'tEf'2fikL Address 9 z Owner <br /> S A e- .t4 Address.— <br /> Firm <br /> ddress -• <br /> Firm Partners, Addresses and Telephone Numbers <br /> M Business Telephone No. <br /> g9 Emergency Telephone No. <br /> a _ v r <br /> Contractor Licence No. <br /> Applicants Name (Print) i -Title - Date <br /> Please check Applicable Category(1-7) and-Fill in.the Required Information ,., r, . ,ti,s . i„:n • , . 1° <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19- --- 4 Disposal Sites — <br /> Description(Make/Yr., Color) _ <br /> Serial No. CAL. License No. CAL. License Renewal No. 3 <br /> Capacity ".n Gal:, Weights & Measures No. 's <br /> Equipment.Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1,�h June 30, 19 <br /> No.of Vehicles Stored y <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST *'rf <br /> R.S. or R.C.E. Name - R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT �� Y <br /> Job Address/Location ca:�n4 /)\j <br /> Owner Address <br /> ® SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 1:1 TEMPORARY 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 Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 x� <br /> Operator Name Where Certified <br /> Plant Location x_ <br /> No. Units Served ” <br /> p�nt Capacity � � _ w <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 /> Meenebry rarlfeealitNadsnt3e prlFHestlre :"IcW tit#tfsrw+Ith*fftslliisissued,Ishallo0entytoyartyperson { <br /> In such manner as to t► ome su Nltlra+Itst�tl's ctunpettiation lawlt of G <br /> Cantrector'i hid or *t*-CW tr ctlna we" e+v%m *a'fa[Mr iinp: -i sertltt►that M theyerfermam ofthewwk for wNeft this perm9t is issuad,t shall <br /> 1 cmptoy persens sub to worllmaa's t a A"Ristlon.laws of 6 hfttrim, <br /> I hereby certify that I hav aced this applicDnd that a ork will bedone'in accordance with San Joaquin Countyordinances, state laws, an r les andre tion n J quin Loc Health District:: <br /> APPL'6CANT'S SIGNATURE X �. <br /> FOR DEPARTMENT USE ONLY . <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January'l &Received By January 31 ❑ July 1 &,Received By July 31 <br /> REMIT <br /> BASE EXPLANATIONBILL NG REMITTANCE ' - M i $ AMOUNT OUE CHECKED <br /> I DATE REMITTED AMOUNT <br /> FEE Ll< <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER. - - <br /> Received by - Date Receipt No, Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1641 E.RAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> i <br />