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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ..- (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is herebyto carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> H Business Name (DBA) I���— -�a� •' AJC Address A019-947k T-4P <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. �— Emergency Telephone No. <br /> Contractor Licence No. zex!l� <br /> Applicants Name (Prink) T �- Title �� Date &—n', <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) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD t <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST i <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. EISANITATION PERMIT <br /> Job Address/Location 7- <br /> Owner <br /> Owner 'eWO& Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL 2LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> O'PERMANENT ❑ TEMPORARY ❑ NEW E�'9EPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> f <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. El PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location ' <br /> Plant Capacity No. Units Served <br /> zP <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 /> 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, d rules and r ulations of a San Joaquirlt.Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <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 /> EASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �L r <br /> LESS <br /> PRORATION <br /> PLUS _ �p <br /> PENALTY <br /> OTHER <br /> OTHER (l <br /> �v <br /> Received by Date Receipt No. Permit No. Iss ance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELT N A O.Box 2009 STOCKTON,GA 95201 <br /> -L-/ a? 1Z <br />