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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. r <br /> APPLICATION <br /> (For Non-Transferable, Revoeable,"and Suspendable) ` SEPTAGE <br /> ' 3� •« ENVIRONMENTAL HEALTH PERMIT I 'fir <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) SLC �� ?s�G10A�_:_ Address <br /> 4 Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers _x <br /> A. Business Telephone No. Emergency Telephone No. �V <br /> a - <br /> Contractor Licence No. -� _ <br /> Applicants Name (Print) Title � 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 /> Description(Make/Yr., Color) w <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. x <br /> Equipment Parking Address �f <br /> 2. ❑ PUMPER YARD <br /> t For July 1, June 30, 19 li e <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST t <br /> g ItR.S.ar R.C.E.No. ` <br /> R.S. or R.C.E. Nam_e <br /> Test Location Test Date/Time <br /> 4. A SANITATION PERMIT - <br /> Job Address/Location _S :57-Pcok-7-e� <br /> Owner �- JA) Addr ss - <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑.PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑l•OTHER;+ ' <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 -t- <br /> Type <br /> Type Construction ;. Disposal Site <br /> No. of Unitsf Equipment Storage/Cleaning Locations) . t <br /> S. ❑ PACKAGE TREATMENT PLANT 'For duty 1, -June 30, 19 <br /> x <br /> Operator Name •r: , Where Certified - <br /> �. _.- - <br /> Plant Location <br /> Plant Capacity ti 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. - 7.j <br /> R5 <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 reg lations of t n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENTUSEONLY - <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 /> r BASE EXPLANATION BILLING REMITTANCE $ 4. �AMOUNTDUE- CHECKED <br /> B DATE DATE REMITTED AMOUNT <br /> i FEE <br /> LESS r t; <br /> PRORATION <br /> PLUS <br /> PENALTY' <br /> OTHER <br /> a • <br /> OTHER <br /> Received'by Date Receipt No. Permit Wo. i Issu nc ate Maile - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICE$ - 1601 E.HAZEL E.,P.O.box 2009 -STOCKTON,CA 95201 <br />