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'. ~> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 7 <br /> APPLICATION <br /> Non-Transferable, Revocable, and Suspendabl SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT Q 11 06, <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in th juri dictional area of the San Joaquin Loc I He Ith District. <br /> ,F Business Name (DBA) �� 0U1N ' Address a <br /> � i CYC <br /> z Owner V f ��' �'� Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. vr7i Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name(Print) FCGt �Url'1� Tltle3r _J���� Date. <br /> r I <br /> Please check Applicable Category (1-7)and Fill in the _Required Information <br /> N (FOt 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATIOR EACH VEHICLE) <br /> For July-1; June 30, 19 Disposal Sites. <br /> 1 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity, Gal., Weights & Measures No. <br /> Equipment Parking Address i <br /> 2. ❑ PUMPER YARD I <br /> For July 1, June 30, 19 - <br /> No. of Vehicles Stored _ 1 <br /> No. of Chemical Toilets Stored <br /> 3. PERCOLATION TEST J U, ! <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. �CC N : <br /> Test <br /> ,Test Location 7- Test Date/Time���7 8'� 7g° <br /> 14. ❑ SANITATION PERMIT - d <br /> Job Address/Location <br /> Owner Address a <br /> ❑ SEPTIC TANK; ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT [" <br /> ❑ PERMANENT ❑TEMPORARY © NEW _ ❑ REPAIR ❑ OTHER \ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 41 t <br /> Type Construction Disposal Site <br /> .No. of Units Equipment Storage/Cleaning Location(s) <br /> fi. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name -- Where Certified <br /> Plant Location f <br /> Plant Capacity No, Units Served <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 /> 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 ruI s nd regu tions of the San Joaquin Local Health District. <br /> s i <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY ' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juty 31 <br /> BILLING - REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> PATE DATE REMITTED <br /> AMOUNT . <br /> FEE <br /> LESS <br /> PRORATION - - - - - <br /> = PLUS <br /> # PENALTY - <br /> OTHER <br /> 1 <br /> OTHER <br /> ceived by Date Rece pt No- Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2:ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201- <br /> J <br />