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Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTheApplication, <br /> APPLICATION I <br /> R (For Non-Transferable,Revocable, and Suspendable) = SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> t f LIQUID WASTE <br /> Application is here�y made t�carry on business in the jurisdictional area of the San oaquin Local Health District _ <br /> Business Name (DBA)_ �/'�% /v G G C-' Address JG <br /> aOwner-- -4 Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Emergency Telephone No <br /> Contractor Licence No. <br /> Applicants Name (Print) Z7 .Title - Date. - <br /> Please check Applicable Category (1-7) and Fill in the Required Information t <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 /> F 1 <br /> 2. ❑ PUMPER YARD ; <br /> For July 1, k June 30, 19 } <br /> No. of Vehicles Stored 'r <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name t ^. ^A R.S. or R.O.E. Nm + <br /> 1.4.1 1. i <br /> Test Location I - Test Date/Time ` <br /> 4. 11 SANITATION PERMIT -4 ;1 I <br /> Job Address/Location �` _ <br /> O,wn n � �� Address l <br /> GR SEPTIC TANK # ❑ CESSPOOL �EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT, <br /> ❑T PERMANENT ❑ TEMPORARY ❑ NEW ❑ REI AIR!S:d- ❑ OTHER,.-T,. 4 } <br /> 5. ❑ CHEMICAL TOILETS For July 1,-.June,304 1.9 <br /> Type Construction =.r4.� Di�osal Site l <br /> 1 i <br /> No. of Units Equipment Storage/Cleaning tLocat n{s}- ; f <br /> 6. ❑ PACKAGE TREATMENT OLANT' For July 1,-June 30, 19 _ r <br /> Operator Name -Where Certified <br /> Plant Location _ <br /> Plant Capacity t :rN Vis.Units Served <br /> 7. E] LAUNDRY For July 1, -June 30, 19rr.. <br /> SIZE: 13Less Than 1,000 Sq. Ft ❑.More Than 1,000 Sq" Ft. } r l 4= i <br /> :1DRY CLEANING.,Chemicals Used/Amount/Mo. { 1:1 <br /> I hereby,certify that I have prepared'fliiis p kation and that the work will be done in accordance with San Joaquih County <br /> ordinances, state laws, and rules and regulan San Joa iri Local Health,District. t I <br /> 3 <br /> APPLICANT'S SIGNATURE X <br /> FOR`DEPARTMENT USE&NLY ' z <br /> Fee Is Due: 13NU <br /> ANALLY,,, ❑ PER UNIT 1 ElPER SITE ❑ EACH El •January 1 B,Received ByJanuary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> w 1, <br /> BILLING REMITTANCE AMOUNTDUE <br /> S CHECKED <br /> BASE EXPLANATION �*�. <br /> 1 DATE DATE REMIT7Fp <br /> AMOUNTl 3 <br /> �[ t <br /> FEE <br /> LESS I 1 A <br /> PRORATION <br /> 2 <br /> _�LUS <br /> ENA TC,Y_....d ..*^tea -.- _ _,�. r __•-�rr� _�az.� -. r — »., <br /> OTHER <br /> OTHER <br /> Received 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 />