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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 on business in the jurisdictional area of he SaL Joaquin Local Health District <br /> y Business Name (DBA) i&y i?tS �,I�g���?�Addressll& 144'-0 !`tea ZID1 — <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> 1 Contractor Licence No. y <br /> Applicants Name (Print) Title MAII,, }ACV <br /> - 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 /> Equipment Parking Address 4 <br /> 2. ❑ PUMPER YARD t c e <br /> For July 1, June 30, 19' , <br /> No. of Vehicles Storedb'� r <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 /> Te cation ' Test nate/Time <br /> 4. PSANITATION PERMIT <br /> Job Address/Location—P045, <br /> _.3.. C AeA4 --- <br /> O ner Address Sg7o3 <br /> EPTIC TANK r C1 -CESSPOOL ACHING FIELD 13SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY '19NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units w " Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name - "+.k Where Certified <br /> Plant Location <br /> Plant Capacity 1 No. Units Served <br /> 7. 13LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than'11,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> . *1_..i <br /> hereby certify that I have repared this application and that the work 1 be don in ance with San Joaquin County <br /> ordinances, state laws, regulati of the oaquin al ealth D' tri t. <br /> APPLICANT'S SIGNATURE X <br /> V Al <br /> FOR DEPARTMENT Yr <br /> N Y <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ E CH January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING ITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> den <br /> FEE <br /> LESS j <br /> PRORATION <br /> PLUS 1 <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 1601 E.HAZ T N AYE.,P.O.Box 2009 STTOCK? N,CAA 5201 <br />