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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 hereby made to carry business i thejkrisdictional area:of•the an doaquinrLocal Health District t <br /> y Business Name (DBA) IC `^1 Address --® <br /> z Owner Address <br /> a <br /> 0 Firm Partners, Addresses and Telephone Num'Vers <br /> J <br /> aBusiness Telephone NEmergency'Telephone N_o. R� <br /> Contractor Licence No. -Z- �Z"t-�•� x. <br /> r c, <br /> . _ Applicants Name`{Pint•) � Title. i j a Date <br /> Please.check.A_pplicable Category (1-4)and Fill in theilleciolred,Information <br /> 1. 1:1 PUMPER VEHICEE'PERMIT REGISTRATION (FOR EACH VEHICLE) { 04) <br /> Q —'- <br /> For <br /> eFor July f June 30, 19 Disposal.Sites <br /> Descri.tion Make/YrtColor +` <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> 'Equipment Parking Address ## <br /> 2. ❑ PUMPER YARD s <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> 'No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST # <br /> -R S. or R.C.E. Name R.S. or;R.C.E. No. <br /> Testi Logon Test Date/Time <br /> i! 44 M SANITATION PERMIT <br /> fob Address/Locatti n.nnP^�s�t P l��r 1 CA.%j ��=►'ACL <br /> Owner t-�rr� _ _►%i� - - Address .i . ± O <br /> ❑ SEPTIC TRNK ❑ CESSPOOL ❑ LEACHING FIELD11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> 01PERMANENT/,, f❑ TEMPORARY 0-0 NEW 2 REPAIR �V i HER 5 t, h-) <br /> -j-. •_ <br /> f 5.6�©tCHEMICAL Tal LETS FQr J.uly 1,F iJ,ine 30, 19 <br /> Type-Construction ; Disposal Site <br /> No,�'ot lJnit �s .r-"`"� � Equipment Storage/Cleaning Location(s) 1 <br /> r 6. PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br />' Operator Name i Where Certified <br /> Plant'Location ! I <br /> Plant Capacity - - .. -----,.No.Units-Served <br /> 7. ❑ LAUNDRY For July 1, -June 30,19 € <br /> SIZE: ❑ Less Than. Sq. Ft., ❑ More Than 1,000 Sq. Ft. s <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. A Y € <br /> Hor»eeivweeecAcea>otda ntQaipi�p„recartHiBathefoilow7tig: Icertifythatinthepsrformancaofthewoirkforwhkhthispermitisissued,is3FallActemployanyperson <br /> In such manner as to become sutJfeet fe arBYkMd fcorrlpeCrs2tiod4aw5 5f 0a#rkirnia."•�.„.,...�_„�-�... i <br /> emmo etc's yi A Ar sub-ctmu'aCeng worwure tomes the fotiowinp:i 1 eeOIN that in the perfo*mance of theilvufkfor`1t+Melitlljs�ertlEit isissillO&I_*,aal�I- <br /> V Y P tr C to workman's catmpeasaz on lams of California." <br /> I hereby'cerEify that 1`have prepared-this appiicatiori and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a rules and r lations of the San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE_ X <br /> -FOR DEPARTMENT USE ONLY <br /> I <br /> Feels Due: 1:1 ANNUALLY El PER UNIT 11 PER SITE ❑ EACH' 1:1 January 1.9 Received By�January 31 ❑ July 1 &Received By July'31 <br /> t <br /> REMIT <br /> BILLING REMITTANCE $ t ' <br /> i <br /> .BASE EXPLANATION AMOUNT DUE CHECKED <br /> { DATE DATE REMITTED AMOUNT .` <br /> FEE r0 <br /> LESS 1 L <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER. - f-. <br /> OTHER.' <br /> i <br /> Received.by _ - Date [ Receipt No., Permit No. Issu nee D to (/ Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: •ENVIRONMENTAL HEALTH PERMITlSERYICES 3 1601 E.HAZELTON AVE.,P.O Box 2009 'STOCKTON,CA 95201 <br />