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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> 4 (For Nan-Transferable;Revocable, and Suspendable) SEPTAGE co <br /> I ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local,Health District <br /> E <br /> Business Name (DBA) _ /����� Address <br /> I. y ��_�_ �. ,�+ — _L <br /> i z Owner AjJ <br /> j. Address r1�` <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 1 q Business Telephone No. �? '�1 Emergency Telephone Na. <br /> I Contractor Licence No. <br /> Applicants Name (Prink) o-Lc Title 'r-�'�J Date —�""`�� <br /> Please check Applicable Category (1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> r Description(Make/Yr., Color) <br /> Serial No. <br /> CAL, License No. CAL. Llczn3e Renewal No. <br /> j Capacity Gal.,Weights & Measures No. <br /> 4 ' � <br /> Equipment Parking,Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> I No. of Vehicles Stored <br /> 3 <br /> No. of Chemical'Toilets Stored G <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name a i R.S. or R.C.E_No! "' g <br /> Test Location t Nest Date/Time 1 �f <br /> 4. 13 SANITATION PERMIT ` �1'7='­117 IzI <br /> Job Address/Location z 93 Ute. ``?• ;7 <br /> Qw r 4 ► —1 <br /> ,.,� 1 ❑ CESSPOOL EACHING FIELD 0 SEEPAGE PIT PACKAGE PLANT i � <br /> lLJ'SEPTIC TANK ; � , _ ' <br /> ❑ PERMANENT 13TEMPORARY NEW 1 i. D REPAIR ❑ OTHER e <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 4 <br /> 4— i ¢ <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 <br /> Operator Name j Where Certified ' <br /> ' Plant Location * # <br /> Plant Capacity No. Units Served <br /> I. 7. ❑ LAUNDRY '.For July 1, -June 30, 19 ; <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> El.DRY CLEANING, Chemicals Used/Amount/Mo. <br /> - _41F <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, and rules-and_r, ulati .sof the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X — ti <br /> i s FOR DEPARTMENT USE.ONLY <br /> Fee Is Due: © ANNUALLY .❑ PER UNIT WIPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑;July 1 &Received By July 31 <br /> 4 t REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> a SASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> w" <br /> FEE <br /> LESS ' ! <br /> PRORATION > <br /> PLUS <br /> PENALTY <br /> r <br /> ;—OTHER- <br /> OTHER <br /> OTHER OTHER �` ... <br /> i <br /> Received by DateReceipt No. Perm' Issuance Date Mailed Deilivfred, <br /> s{. <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO KTON 5201 - <br />