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Applications Will Be Processed When Submitted ProperlyCompleted. tieSure t,oalgn ITiC^Nr••�a•'�" <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) E- SEPTAGE <br /> 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 /> s. s L.ID�.LSO Address ��L /✓ Tb1 ST" Z�oG [.o <br /> w Business Name (DBA} r3 C.�4�/�f <br /> k a Owner L aJ GHIDi2� Address €�s <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Emergency Telephone No. <br /> Business Telephone No. <br /> a01 e <br /> Contractor Licence No. Date <br /> t ad� 6 [4Sc_f Q•• Title <br /> 11 Applicants Name (Print)_. <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 /> F. Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> k For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> j 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. Vf SANITATION PERMIT ri <br /> r <br /> Job Address/Location <br /> j <br /> Address <br /> net 11• d <br /> AL1 LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT <br /> O <br /> SEPTIC TANK 1:1 CESSPOOL ❑ REPAIR El OTHER { <br /> 11 PERMANENT 11 TEMPORARY NEW O <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 /> r. 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> r Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 les and regulations f the Sa Joaquin Local Health District. <br /> G 4 � <br /> 4 APPLICANT'S SIGNATURE X <br /> F <br /> FOR DEPARTMENT USE ONLY <br /> rcf^ `EACH ❑ January &Received By January 31 ❑ July Received By July 31 <br /> Fee IS Due: ❑ ANNUALLY PER UNIT 4a PER SITE ❑ 1 REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE - EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION. <br /> PLUS <br /> PENALTY <br /> k, <br /> OTHER <br /> OTHER <br /> 7 D 30 ?b 6 <br /> D to Receipt No. � Permit No � Issuance Date Mailed elive d <br /> Received by - <br /> ­APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AYE.,P.O.Box 2009 STOC TON,C 95 1 <br />