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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. T <br /> APPLICATION <br /> (For Non-Transferable,=Revocable,and Suspendable) / <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT � ! <br /> LIQUID WASTE V <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rn Business Name (DBA) A 4 AddressJ7rX_X, - <br /> aOwner Address _ <br /> 70 Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. 1!9kS'"3971_.: Emergency Telepho e No. <br /> Contractor Licence No. .;t7 <br /> Applicants Name (Print) GGcI'yD L�EJf�� a .Title - Dat/e9-.7, —AZ' <br /> Please check Applicable Category (1-7)and Fill in the Required Information # ti s_• y <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) W <br /> For July 1, -June 30, 19 Disposal Sites <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 <br /> 2. ❑ PUMPER YARD /• <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored t <br /> 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 /> Job Address/Location �� W� � �,•—_S"Tt9GIc�� G'4 _- _- -- <br /> Owner Q V)RR J kJO P—c..c..A Address �- l- <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR OTHER / V 1 <br /> S. 11 CHEMICAL TOILETS For July 1, -June 30, 19 "• I 46,M12j&A, C <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 Where Certified <br /> Plant Location <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 /> F#orrrneewller�rTa�an��A ;+ •-o: n. s o vlRn: t`P!tif l 'tnth r .�• <br /> r. art nle r-@rwrr istthef�tl , "1 r.`ar I ilCeofih_ v r. f <br /> i u a^r , c <br /> /r�lt�'S�G�SFI, '8`, i ^•` dt� r <br /> •ilBStfii �lQr'C i:fit;?'. C%: ;;;3 A L 1'IIf:Ct,f/ 1 :r' ..Y.� <br /> _ y L•E rta:... '.!eR lasawrn 1 Certrfy Iiiai 111 fi:C s:!'9:S'rfta;1CC a+ray 1';Uii.TQ; 1,,,..�1_} �,;,:,.:-.o.,.�•.,'.�,i i-taL <br /> e6 t LS4a7y«tf 1jLCt Ip'�ul rr3llS CG 11�1C;ia�lliVii idW$pI(6lilorniC <br /> k � <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqujry,County <br /> ordinances, state la and rules and regulations of the San Joaquin Local Health District. <br /> d <br /> :APPLICANT'S SIGNATURE X + <br /> u, FOR DEPARTMENT USE ONLY r p <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE o <br /> i <br /> LESS <br /> PRORATION J <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date -ReceiptNo. .Permit No. Issbancd Date !Nailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />