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Applications.Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION C) �y 090 6 <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application isehereby made.to carry on business in the jurisdictional area of the Sa J'oaq}uiin Local Health District <br /> rr r �­ x­ <br /> AddressO Business Name (. BA) - -z Owner ", e. * Address <br /> a ' <br /> J Firm Partners, Addresses and Telephone Numbers ` <br /> Emergency Telephone No. <br /> a. Business Telephone No. 9enc Y P x <br /> Contractor Licence No. <br /> a <br /> 'f Applicants Name (Print) - Title Date- — <br /> L .. <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 30,119 Disposal Sites <br /> Description(Make/Yr.;'Color) <br /> Serial No ,= CAS_. 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, i9 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored - <br /> 3. ❑ PERCOLATION TEST <br /> ¢ No <br /> E <br /> C <br /> R <br /> R.S. or . . . . <br /> R.S. or R.C.E. Name _ <br /> Test Location- Test Date/Time <br /> 4. ❑ SANITATION PERMIT : ' > '� <br /> Job Address/Coca ion w ""x,.` 14' <br /> orP^ ► ` Y""`7 r <br /> Owner AddressW. _ <br /> 13 SEPTIC TANK 11PIT <br /> CESSPOOL C EACH ING FIELD'. ❑ SEEPAGE - 0 PACKAGE PLANT <br /> D"PERMANENT ❑ TEMPORARY L� NEW ,s w 3❑-REPAIR ❑ OTHER f <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 }4 �` <br /> Type-Constructiori -' �, Disp_osal�Site <br /> No. of Units = a`Equipment Storage/Cleaning Location,(§)'' =•" <br /> 6. ❑ PACKAGE TREATMENT:PLANT ,For July 1, -June 30, 19 <br /> ' <br /> Operator Name`, . Where Certifled <br /> ." - - � <br /> Plant Location <br /> Plant Capacity _.No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30''19 v` <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. _ <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Me: T _ <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 arld regulations of the San Joaquin Local Health District. 1 <br /> APPLICANT'S SIGNATURE X �.�i ''�' <br /> 5,4-9-0 :L++- <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: Cl ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 - ❑ July 1 &Received By July 3 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE: i g1 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date - Receipt No. ;Permit No. issuance Date Mailed Delivered <br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 160TE,HAZELTON•AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />