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°r � v <br /> Appficatitins Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION . _ <br /> (For Non-Transferable, Revocable, and Suspendable) R SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ' LIQUID WASTE <br /> Applicati is e?ebyAiade to carry on usin ss in the jurisdictional area of th San Joaquin Local Health Distr.,icctt / <br /> Business Name (DBA) a� N F�'i�it) 1 w Address ib 130?c l�.�lJ --szt::� Frlaz <br /> z Owner Address <br /> a <br /> Firm Partners,Addresses and Te"Iephonne/Numbers . <br /> aBusiness Telephone No. _7�I1 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) -cs.t%.C/�,� ��i�i(IQEF�_ Title exx Date :A/S"/orz) <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) JL <br /> Serial No. f! CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <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 <br /> 3. ❑ PERCOLATION TEST I <br /> ! R.S. or R.C.E. Name I R.S. or R.C.E. No. <br /> Test Location )� Test Date/Time _ <br /> 4. W SANITATION PERMIT <br /> Job Address/Location F, , <br /> 1� <br /> Owner Address Z 36=- <br /> NS EPTIC <br /> 6=-® SEPTIC TANK ❑ CESSPOOL El LEACHING FIELD- ^'T ❑PACKAGE PLANT <br /> ❑ OTHER <br /> ^^` <br /> PERMANENT ❑ TEMPORARY .� NEW �,rr <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site `) <br /> C. No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT',PLANT For July 1, -June 30, 19 <br /> Operator Name i� Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -II une 30, 19 <br /> SIZE: El Less Than 1,000 Sq'. Ft., ❑ More Than 1,000 Sq. Ft" <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that'! have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state IavaA, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE XE�! <br /> r l� FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY li ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BELLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> ►' FEE d <br /> 71 <br /> r kJ <br /> LESS <br /> PRORATION I) <br /> PLUS <br /> - PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> - APPLICANT—RETURN ALLCOPIES TO: ENVIRONMENTAL-HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.eP.O'Box 2009 STQCKTON,CA 95201 <br />