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V_-F r Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> F ,�i � APPLICATION 9 <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> 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 /> OF Business Name (DBA) F11 Address <br /> z ti��—.J. Address r <br /> a Owner <br /> Firm Partners, A dresses and Telephone Numbers <br /> D3 f — 9LB Emergency Telephone No. <br /> a Business Telephone No. <br /> 4 Contractor Licence No. _ <br /> �Applicants Name (Print) e' y W -Title O w Qf L� /Z Date <br /> ' Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> fJune_30, 19 Disposal Sites <br /> For July 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 4 <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> t 3. ❑ PERCOLATION:.TEST <br /> I <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. 0 SANITATION PERMIT TO <br /> Job Address/Location <br /> rr Owner Address <br /> [ ❑ <br /> E5 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD E] SEEPAGE PIT ❑ PACKAGE PLANT <br /> � <br /> ❑ PERMANENT ❑ TEMPORARY 0-NEW R'REPAIR �. ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> I Type Construction Disposal Site <br /> No.of Units Equipment Storage /Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, - Jure 30, 19 <br /> _ <br /> Operator Name Where Certified' <br /> � ���� �a <br /> Plarif Location <br /> Plant Capacity No, Units Served y' <br /> ". <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq Ft.. <br /> I ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <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 regulations _the San Joaquin Local.Health District. <br /> APPLICANT'S SIGNATURE X c� <br /> rw <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 13ANNUA C1 PER UNIT 11 PER SITE �KEACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 1 REMIT <br /> t BASE EXPLANATIONBILLING REMITTANCE $ 7AMOUNT] CHEGKED <br /> DATE DATE REMITTED AMOUNT <br /> I � <br /> FEE <br /> t LESS <br /> PRORATION <br /> PLUS �y <br /> PENALTY <br /> F OTHER <br /> —7 L7 3 3—7 <br /> ReceiUrdVy LislePermit N. Issuance Date Maiied Delivered <br /> .. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201. <br />