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r- Applications Will Be Processed When Submitted Properly Completed. Be Sure To,Sign The Application. <br /> 40 <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application la4iorobv made t carry on b iness in the urisd' tional area of the San Joaqui n Local Health Dist ict <br /> OF Business Name ( ) Address �@ ? <br /> aOwner Address <br /> J,Firm Partners, Addresses and Telephone Numbers t <br /> a. Business Telephone No. �S'/ Q S Emergency Telephone No. <br /> Contractor Licence No. 7-2-�- <br /> L Applicants Name (Print) Title bate 2 r G <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. Q <br /> Capacity Gal., Weights &Measures No. (1 <br /> Equipment Parking Address v� <br /> 2. ❑ PUMPER YARD `l <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No, of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST w' <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br />'i 4. ❑ SANITATION PERMIT ! <br /> Job Address/Location Z 3 52— S <br /> Owner Address 4 3 <br /> LEPTIC TAN ❑ CESSPOOL �EACHING FIELD SEEPAGE PIT C1 PACKAGE PLANT �y <br /> ?PERMANENT ❑ TEMPORARY I u NEW ❑ REPAIR ❑.OTHER t� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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. y i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> hereby certify that I have prepared this application and that the work will be done in accordanyvith San Joaquin County <br /> ordinances, state laws, and rules and r lations of the San Joaquin Local Health District. <br /> LA <br /> APPLICANT'S SIGNATURE X 1 <br /> FOR DEPARTMENT USE ONL <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 ceived By January 31. ❑ July 1 &Received By July 31 <br /> BILLING REMITTA E S REMIT <br /> BASE EXPLANATION DATE DAT REMITTED AMOUNT DUE CHECKED . <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit N . Issuance Date Mailed Delivered ` <br /> .`APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601'E.-HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201' <br />