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Appllcatio Isd� I Be Processed When Submitted Properly Completed. Be Sure To SignTheAppucanon. <br /> OCT � � APPLICATION <br /> (For Non-Transferable, Revocable;and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SAN JOAQUI s LOCAL �LIQUID WASTE <br /> till:#IS � � <br /> A�plj9§Yoi�'i5' a eby made to carry on business in the jurisdictional,area of the.San Joaquin Local Health Distract. <br /> rn Business Name (DBA) 4.04• V"" Address <br /> aOwner =- _ - Address . .. <br /> Firm Partners, Addresses and Telephone Numbers <br /> 91. Business Telephone No. Emergency Telephone No _ L. <br /> Contractor Licence No. . . <br /> Applicants Name (Print) <br /> �, Lr1Aa7 Title Date <br /> Please check Applicable Category.(1-7)and Fill In the Required Information-,-'t., <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE} <br /> -'Disposal Sites <br /> For July 1, -- June 30, 19 - . <br /> Description(Make/Yr.,Color) °C <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal:,Weights & Measures No. <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD <br /> For July i, June 30, 19 <br /> -No. of Vehicles Stored <br /> No. of Chemical Toilets Stored - <br /> r 3. ❑ PERCOLATION TEST <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 <br /> I Job Address/Locatiori �'D� d <br /> Owner L <br /> Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT, <br /> EIPERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER 225 VI.S .� <br /> 5. ❑ CHEMICAL TOILETS- For-July -,.7.June 30,-19 <br /> Disposal Site <br /> Type Construction _ • <br /> No. of Units ' Equipment Storage/Cleaning Location(s) <br /> ~ "0, <br /> 6. El PACKAGE TREATMENT PLANT For July 1, -June 30, 19 J <br /> Operator Name Where Certified <br /> Plant Locatiori <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 /> Ho o rmerorlieer.see* �V' n �n r r a I t <br /> ga °, r rth foPowing f rify{*"Zri�f`'anerformar:G pfther✓arkfervrhichthispermitasiss'cd,. h s.l^o:em loy anypv�surl <br /> 5GG�€fnanner aS E-bez, iiSE=i::ajtli+_ .-. <br /> Coatr eerr a hiring or sub-ec.=trrrs'r!4 u;Iilc 6Vor,'+,fa,j!.Uil t r•`' 13 a u,i Sp2Il e <br /> eiT,;ioy por-.-ors;:L'Iljw to wOrkman's c5i:pLGSeiiw€a tilJtiu 61 Calciol=i14." € <br /> I hereby certify that I l ave'prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and.re•gulations of the San Joaquin Local Health District. W. <br /> APPLICANT'S SIGNATURE X <br /> ' FOR DEPARTMENT USE ONLY f <br /> 5 <br /> Fee IS Dile: ElANNUALLY ❑-PER UNIT: ❑ PER SITE ❑ EACH. C3January 1 R Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING I REMITTANCE. $ AMOUNT DUE <br /> j ..• .. r DATE DATE g REMITTED =-�II0f0 <br /> FEE .41 <br /> LESS r <br /> E' PRORATION F <br /> PLUS _PENALTY + <br /> .OTHER - <br /> : i <br /> OTHER <br /> Received by Date Receipt No. Permit Na. Issuance Date , rkdr <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES_ 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />