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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> N ENVIRONMENTAL HEALTH PERMIT <br /> J ` LIQUID WASTE <br /> Applicatio Is h eby ad to car on bu Ine In the jurisdictional area of the S Joa Local Health District <br /> y Business (DBA) �� -mss-+ Addraspp i �� <br /> z Owner—f 7`Fi �4 Adddrrre,.ss2� <br /> u Firm Partners, Addresses and Telephone Numbers r <br /> a Business Telephone No. .��'�-313.3 Emergency Telephone No. <br /> a ., <br /> Contractor Licence No. <br /> Applicants Name (Print) �/ rCf� ST !£ Title uC1_)A)t^ Date S= 7® 1 <br /> Please check Applicable Category (1-7)and Fill in the Required Information w <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. 11SANITATION PERMIT <br /> Job Address L cation "�� <br /> Owner (. sEsf- Address 7 AAC <br /> ©"SEPTIC TANK ❑ CESSPOOL CrLEACHING FIELD 8'§-EEPAGE PIT ❑ PACKAGE PLANT r <br /> 2-'PERMANENT ❑ TEMPORARY 9��EW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site ZDNo. 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 th' a pli ation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, r s d r ti of the San Joaquin Local Health District. <br /> C <br /> APPLICANT'S SIGNATURE <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 REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED J <br /> AMOUN <br /> 00 <br /> t3� <br /> FEE c L <br /> LESS 1� <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 0 s <br /> Received by Date Receipt No. Permit No. I suanc Date I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> r,4VJ,"td 17 4u ECS 6 N'W1 �. <br />