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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION _ , <br /> f (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> (( ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> K Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) /SiK Sd+.tJl. 2�.t�ec• Address l O � JL) <br /> z Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers ' <br /> aBusiness Telephone No. 4' ,9407 Emergency Telephone No. <br /> Contractor Licence No. -2,Applicants Name Name (Print) fJlt-EC< <itsS Title �S� 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 <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 �1 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST t ` <br /> R.S. or R.C.E. Name R.S. or R.C.E.No. <br /> Testi Lotion Test Date/Time <br /> 4. � SANITATION PERMIT <br /> Job Address/Location � �' /¢«G�� 257i01L. <br /> Owner `GO ce -f S Address �� �/�� <C1s� Vr"-V"_ 15 ►n&oO 9'SZO7 <br /> ❑ SEPTIC TANK ❑ CESSPOOL BEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ®'PERMANENT ❑ TEMPORARY ❑ NEW O'REPAIR ❑ OTHER <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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that he work will be done in accordance with San Joaquin County <br /> s, <br /> ordinances, state lawd rules and r gulatI s f the n J quin Local Health District. b <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT to PER SITE ❑ EACH ❑ January 1 &Receiv d January 31 ❑ Ju Received By July 31 <br /> BILLING REMITTANCE (( REMIT <br /> BASE EXPLANATION DATE DATE LTZ AMO DUE CHECKED <br /> IN aii AMOUNT <br /> FEE Gc v/ Y <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> O-? <br /> Received by Date Receipt No. Permit No. Is uance Date Mailed "Del, <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCA 201 <br />