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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> ti .sr (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> L,. 17 ENVIRONMENTAL HEALTH PERMIT <br /> 88,02 LIQUID WASTE <br /> Application is heyy made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> UF Business Name (DBA) BOIJ177 4 ���Q2z Address -?3W EW7?4d(7C-',1'. <br /> a Owner ler, 1'� ClQJO�'db{J(/� Address some <br /> Firm Partners, Addresses and Telephone Numbers Terrf azz7 <br /> a. Business Telephone No. cJt�?8�g�r1 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print)GiW- 7&Ua7- fd!-- 10hl7V= !e'en Title CIIZIl % Date V/Z41.A <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 y <br /> R.S. or R.C.E. Name_ G ii R.S.or R.C.E. No. <br /> Test Location 7� 0 V ArM5t Mq0 Tact nate/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ 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 /> Homeownr►wticsaosdwt'o Comm ypersor <br /> in such mailer as to Xi <br /> contwletor'a M or strY-aawuaefiag sipnh um ceNifl . 1%" +ovew'.' ttifq ttw*�1 inu pei"amr4ncu�,the work for whid, t�i�,p reulr> ued,I shall <br /> mph p t�to workmws ca ieR taws of calico aka �1 ' C1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joh ICb%i,f�� �y <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. °,': r` (' <br /> APPLICANT'S SIGNATURE X <br /> For Pard l A it `/ �� EN��QERMI�ISER <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Rece' d by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />