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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.f <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) �`. ;SEPTAGE.,_ _ <br /> ENVIRONMENTAL HEALTH_P.ERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in-the jurisdictional area of the an Joaquin Local Health District <br /> ,F Business Name (DBA) � <br /> �};L� 151-� . . � Address <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers — <br /> a. Business.Telephone.No. -- 4&6?`r .,�1:9.07 Emergency Telephone No. <br /> Contractor Licence No. ZS <br /> L Applicants Name (Print) tlJ L�y �1 s _- Title Date 6-1-7 <br /> Please check Applicable Category (1-7)and Fill.in the Required Information <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> +� <br /> For July 1, L 7 June 30,-19 - Disposal Sites " <br /> Description(Make/Yr., Color) l <br /> Serial No, CAL. License No. CAL. License Renewal No. r` <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. "❑ PUMPER YARD <br /> .Fo 'my 1, June 30, 19 •" x <br /> Noy o Vehicles Stored <br /> No. Of Chemical Toilets Stored <br /> 3. 0 PERCOLATION TEST .. <br /> R.S. or R.C.E. Name R.S. or R.C.E.No. <br /> Testi�Location - Test Date/Time <br /> 4. 1L= ANITATION PERMIT <br /> i r �,�,� _ <br /> 'job-•AdV+4 <br /> dress/Location 2 7�S _ 1L- f2d • .�lhal�l� t�a/y � - - <br /> ' SAN-WS HAC%_ 1&t. Address Jpfl•_� t• 72 _. � :r In <br /> Owner- �`']k �©l�--fi1 t� � <br /> B'SEPTIC TANK ❑ CESSPOOL 0 LEACHING FIELD ❑ SEEPAGE PIT "El-PACKAGE-PLANT' 4 {4 <br /> tCPERMANENT 0 TEMPORARY C?ILEW ❑ REPAIR .14�© 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 /> LOperator Name y +Where:Certified <br /> 'Plant Location <br /> 'Plant Capacity R �' f No. Units Served <br /> 1. ❑ LAUNDRY For"July 1, -June 30,19 <br /> ISIZE: ❑ Less Than.1,000 Sq. Ft., 0 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO. <br /> hereby certify that I have prepared this appand t the work will be done in accordance with.San Joaquin Courtly <br /> ordinances, state laws, %rl -an/rulatioRnth e n oaquLocal Health Districts ° 'A <br /> I i r t'� -• }f - <br /> 'APPLICANT'S SIGNATURE X <br /> {_ A <br /> P i <br /> t FOR DEPARTMENT USE ONLY j t` <br /> ' Fee Is Due: ❑-ANNUALLY ' ❑ PER UNITS _ ElPER SITE ❑ EACH ❑ January 1 &Received By January 31 :❑ July 1"&Received By July 31 <br /> REMIT s <br /> BASE F EXPLANATION BILLING REMITTANCE r $ 1. AMOUNT DUE . CHECKED <br /> DATE DATE * REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> � PRORATION <br /> PLUS <br /> PENALTY i a <br /> OTHER 3 1 <br /> if <br /> t <br /> f.,,iOTHER, '..-.. . ...�.� � ..: .. <br /> CA <br /> Received by Date Receipt No, Permit No. Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZE},TOOAV 0.BoK 2009 STOCKTON,CA 95201 �I <br />