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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> '1 +, (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> .111117 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> N Business Name (DBA) ���✓ PA.P,r?/ So.c/S Address PO BoaC l�Gi�, SrvC'.�T�al 9Ss-o/ ' <br /> z Owner Address <br /> a � <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. �4 G 9 © <br /> 6Z Emergency Telephone No. -� <br /> C� <br /> Contractor Licence No. <br /> Applicants Name (Print) It'LQ,�i> LSO o Title E S Ti.�s A r� Date /Z <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 <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. 0 SANITATION PERMIT <br /> Job Address/Location gAiB 0, od 4 101W15A) <br /> Owner 7—,q A< tel./A T,4dzA6,c Address S14"Al- W <br /> ❑ SEPTIC TANK ❑ CESSPOOL I LEACHING FIELD 19 SEEPAGE PIT ❑ PACKAGE PLANT N <br /> 51PERMANENT ❑ TEMPORARY ❑ NEW 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 the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and rules and regulations oft a oaquin Local Health District. <br /> APPLICANT'S SIGNATU E 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED (� AMOUNT <br /> FEE D ' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7 <br /> �7g <br /> Received by Date Receipt No. Permit No. Issuances Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />