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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. M <br /> '; &w''`-- APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE ' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 4. y LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District, <br /> r Business Name (DBA) g 'X19 a� Address lif�G Grr7`7't� <br /> m <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No.���r^3-q��' - - Emergency Telephone.No. <br /> 1 Contractor Licence No. <br /> LApplicants 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) <br /> Serial No. CAL. License No. CAL- License Renewal No.. <br /> Capacity Gal., Weights & Measures No. <br /> I <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored t <br /> 3. ❑ PERCOLATION TEST ? <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. b�SANITATION PERMIT <br /> Job Address/Location <br /> Owner t- Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD EEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY EW ❑ EPAIR ❑ OTHER <br /> I 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site !n <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. <br /> ❑ pPIN rG _ g't, + Is Used/Amount/Mo. <br /> G�1 > <br /> �113t3 YY�ullflu ' 3f Z .;�i�{��1.1t%�Fact?s:aFshi�F 1+gtrtRa ln�s h .a <br /> 59 tf t,rliln s 11,t 'C If tai 1;ifl S idi14- +s $s s" i, he 'jneaCs t;lr 6tlC1'IS for <br /> ir�si8'r_a Y1is�, 3F l j3 fi8:, �] :o- iC#;ri i^;mit l�i,^,rl3r!N,1 sitntl is©t @�ip1e3l3�y prZrSu9 fl <br /> ^'y iRcI�EI'-�3te2:;1 4 •-.drtri.;,, . <br /> :. ( 3+i s9n}Sffi�%f k4.aS'¢m$IiINI�ti•�KGSI 'Itealimf14t'yii�tsflti:l}: ' I. .•i e"i[133113eperforn3anCeofti3e1Y6rt{iCf'tti;l3iCh':.illSP.Ei�iill ISS(!E{I,{�S <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 regulati o oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X i <br /> FOR DEPARTMENT USONLY. . <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 /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION v <br /> PLUS {/� <br /> PENALTY <br /> OTHER ' <br /> OTHER .;.. <br /> Received,byi Date Receipt No. - Permit No,- Auanct Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERVICES' 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />