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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applic$tton. <br /> APPLICATION � <br /> (For Non-Transferable, Revocable,and Suspendable) � <br /> /' SEPTAGE <br /> I ENVIRONMENTAL HEALTH PERMIT <br /> !� LIQUID WASTE <br /> Applicati0 is hereb map to carryon bu iness in th jurisdictional area of the San Joaquin Local Hee Distri t S <br /> HBusiness Name (DBA) JIL Address //''.�"� ,fes ' <br /> a Owner (�A- Address !l'48C�1&' ^C 1 r' S'rXy k. DA-) <br /> Firm Partners, Addresses an Telephone Numbers <br /> aBusiness Telephone No. 31 � Emergency Telephone No. <br /> Contractor Licence No. & <br /> L Applicants Name (Print) Title 6 LU,1 ,o_V Date <br /> Please check Applicable Category(1-7)and Flll n 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 <br /> No. of Vehicles Stored <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 /> Test Location Test Date/Time <br /> 4. ❑ SANITATION t/PERMIT <br /> � <br /> Job Addre s/Locatio`n`t�� +Z 0 A) QLp <br /> Owner �,Ila. SDI' AJ9 C,-J_ 19 - Address D 17 90 1 AA CA I � <br /> PYISEPTIC TANK ❑ CESSPOOL ®.LEACHII g IEAI.� ❑ SEEPAGE PIT ❑ PACKAG PLANT <br /> 11 PERMANENT ❑ TEMPORARY 13 NEW f/��++ ❑ REPAIR ❑ OTHER 0 -� <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site O <br /> No. of Units Equipment Storage/Cleaning Location(s) "- <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 71 <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 the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules a ulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <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 ITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> O <br /> FEE s 41'- .JC <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date I Receipt No. Permit No. Issue e D Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZE E.,P.O.Box 2009 STOCKTON,CA 95201 <br />