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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> i APPLICATION <br /> f (For Nan-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appiicatio hereby ma o car o buslnes in the jurisdictional area of the San Joaquin Local Health District _ <br /> ,F Business Name (DBA) ���� 4 4V Address Ives 5,::) � r <br /> M z Owner t'! Address 4 -5c), �''� G r <br /> a <br /> 9 Firm Partners, Addresses and Tele hone Numbers <br /> a. Business Telephone No. —� / Emergency Telephone No. <br /> _jContractor Licence No. f� <br /> a -. -*•� �= Title $ Date <br /> L Applicarts6N8me,(Prliit)" <br /> Please eck Alpplicable'Calegdry (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER IIEHICLE,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 Nd. <br /> Capacity Gal., Weights &Measures No. <br /> ( Equipment Parking Address <br /> 2. ❑ PUMPER YARD {� <br /> For July 1, June 30719 _ <br /> �!�R* ► <br /> No. of Vehicles Stored <br /> No. of Chemical Toiets Stored <br /> r <br /> 3. © PERCOLATION TEST+V � <br /> ' R.S. or R.C.E. Name R.S.or R.C.E. No. N <br /> Test Date/Time <br /> Test Location l <br /> M 4. SANITATION PERMIT ;.� <br /> Job Address/Location 4 ' .©5 `.•fix C,0�1;, ` " <br /> �0 '3' ` ` <br /> Owner �Z Address <br /> f' ❑ SEPTIC TAN�Is . El CESSPOOL LEACHING FIELD EI SEEPAGE PIT 13 PACKAGE PLANT <br /> f 11PERMANENT,A" 11 TEMPORARY i ❑ EW REPAIR OTHER � rnp <br /> 5. ❑ CHEMICAL TOILETS For July1, -June 3019 <br /> Type Construction _ Disposal Site/ <br /> No. of Units t i Equipment Storage/Clea ing Location(s) <br /> 6. ❑ PACKAGE'TREATMENT PLANT For July 1,- June 3019 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRYVFor 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. v <br /> �I hereby certif that I ha re aced this application and that he work wiltvbe done in accordance with San Joaquin County <br /> y i p p p � � .,"�� 3 b ra}k a yy <br /> il+ardinances, state laws, a 4 ules and regulations of the an icoaquintL-ocal Health District; <br /> APPLICA'NT��SIGNA_ IRE X <br /> –�• ,yy FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLYJ'PER-UNIT�IOd PER�SITE---**[;]-EAGH—CO January'1-&*Received�By January=31—ID-Jtily 1 &Received By July 31 <br /> REMIT <br /> - BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> I <br /> FEE -s r` <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> F <br /> OTHER t <br /> 01 <br /> �i Received'by - Date - Receipt No. _Pe mit No, - _issuan a Date1. Mailed - Deli area $�C 7? <br /> - APPLICANT-RETDRN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES i �, 601 E.HAZELTON AVE.,P.O:Box-20094„ STO KTON,CA 95201 <br />