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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION _ A,; t <br /> (For Non-Transferable, Revocable, and Su�"pendatile) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT t <br /> LIQUID WASTE <br /> Applicat' n is h y e to c r on business in the j risdictional area of the San Joaqu^p L cal Health District y��° <br /> U) <br /> Business Name (DBA)D_� .Address Z,`1r MINI'+_ -�t� �f ,� <br /> i Owner Address <br /> a sZ7 71 2 , <br /> 2 Firm Partners, Addresses and T le hone`Numbers <br /> aBusiness Telephone No. Emergency Telephone No., <br /> Ir <br /> Contractor Licence No e' rr <br /> Applicants Name (Print) y1L�� �4 + Title 6,T 1 Date �- <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> •- � re�tt 3i<;`t> + it ,,,, .� .7..3` t:t <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 N0. CAL. License No. CAL License Renewal No. ! <br /> Capacity ) Gal.,Weights &Measures No. <br /> da b <br /> Equipment Parking Addeess <br /> �zt <br /> 2. ❑ PUMPER YARD <br /> For July June30, 19 # s �{ <br /> No. of Vehicles Stored { <br /> ,No. of Chemical Tollets,Stored <br /> 3. ❑ PERCOLATIO t'ITEST t <br /> R.S. or R.C.E< Name; i R.S. or R.C.E.No. <br /> Test Location, Test Date/Time ` € d -'r <br /> r, I <br /> 4: SANITATION PERMIT <br /> Job Addrecation <br /> O,# <br /> Owner f Address <br /> SEPTIC TANK ❑ CE=SSPOOL ❑ LEACHING FIELD ❑ SEEPAGE-PIT ❑ PACKAGE PLANT <br /> ,PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAI�(R OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 t; o o <br /> Typ#e Construction Disposal Site i f No. of Units f Equipment Storage/Cleaning Location(s) <br /> �. ❑; PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name l Where Certified 3 _ <br /> Plant Location t ( S <br /> Plani Capacity No. Units Served <br /> 7.''`❑ LAUNDRY For Julq-1, -Uune 30,19 <br /> SIZE: t❑ Less Than 1,060 Sq'< Ft.,+ ❑ More Than 1,000 Sq. Ft. <br /> ❑.DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r } <br /> I hereby certifyjthat I have prepared this ap Ilcatlon and that the work will be done in accordance with San Joaquin County - <br /> r <br /> yp Ordinances, State laws,and rule egul io the San Joaquin Local Health District. d <br />'i APPLICANT'S SIGNATURE'X <br /> FOR,DEPARTMENT USE ONLY <br /> Fee Is Due: 11 ANNUALLY ❑ PER'UNIT. ❑ PER SITE ❑ EACHf ❑ January 1 &Received By January 31 ❑ July 1 &-Received By July 31 <br /> BILLING a REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE. y. DATE REMITTED AMOUNT <br /> FEE - <br /> LESS ' <br /> PRORATION <br /> r PLUS c x <br /> PENALTY i... . . i t - . ,. . <br /> OTHER <br /> OTHER l - <br /> tral <br /> Received by Date Receipt No. Permit No. Is anc D ailed Delivered <br /> APPLICANT-RETURN-ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES''"''" 1601 E.HAZELT AVE: .O.`Box 2009 - STOCKTON,CA 95201` - <br />