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letea.veouEc E.. �.�.. <br /> Applications Will Be Processed When SubbmitPLICAT��NProperly p <br /> } (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL WASTE HEALTH PERMIT <br /> LIQUID <br /> business i e iurisdictional area of the San Joaquin L gal Healt D strict <br /> Applicati s hereby m to car d <br /> �tIll Address <br /> -. dS <br /> r Business Name (DBA) Address <br /> k a Owner <br /> 9 Firm Partners, Addresses and Teles.e I`umbers Emergency Telephone No. <br /> aBusiness Telephone Na. 3 <br /> Contractor Licence No. <br /> Titled Date <br /> ' �App'icantsName�'(P.rin1)��`^_ e <br /> I -iicab•- «e E'alegory ( -7 1 and Fill in the Required Information <br /> 1 Please check Appi1 <br /> 1. 0�P,UMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> June 30 19 Disposal Sites <br /> For July 1, CAL. License Renewal No. <br /> Description(Make/Yr., Color) CAL. License No. <br /> Serial No. <br /> Gal.,Weights &Measures No. <br /> Capacity <br /> I Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> G For July 1, June 30, 19 - <br /> ( No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S.or R.C.E. Name .Test Date/Time <br /> Test Location Of <br /> ± q, g SANITATION PERMIT Q D <br /> Job Address-/Location - Address 40o T <br /> Owner13PACKAGE PLANT <br /> ❑ SEPTIC TANK 13 CESSPOOL �LEACHING FIELD SEEPAGE PIT ❑13 NEW REPAIR <br /> OTHER <br /> PERMANENT El TEMPORARY <br /> � <br /> 5, ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> I � Dispbsal Site <br /> i Type Construction <br /> Equipment Storage/Cleaning Locations) <br /> No. of Units <br /> r. g, ❑ PACKAGE TREATMENT PLANT Far July{,1„ -June 3D, 19 <br /> y� � Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> i Plant Capacity <br /> E 7. ❑ LAUNDRY For July 11 -June 30,•19 — — "- <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 0;_-.:R 4`I+T,ee Ems,.., <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO x`y , <br /> ` 4 <br /> I - lication and that the work will be done in accordance with San Joaquin County <br /> I hereby certify fhat"I'have prepared this app r <br /> I ordinances, state laws, a les and regula ions of the an <br /> Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X r <br /> k + _1 FOR DEPARTMENT USE ONLY <br /> I f s' , <br /> �. PERSITE EACH ❑ January,1_&,Received By January 31 t ❑ July 1 &Received By July 31 <br /> .� PER=UNIT lal.°,, _. - xa,_ ar .,. ' F REMIT <br /> Fee IS DIJe: ❑ ANNUALLY ❑' �.. ':,,,,,,,,-,_ CHECKED <br /> "'REMITTANCE $�� AMOUNT DUE AMOUNT <br /> REMITTED <br /> g - BASE EXPLANAT DATE DATE ..a <br /> FEE <br /> �.. <br /> LESS <br /> PRORATSON /f n <br /> PLUS <br /> PENALTY .. <br /> y <br /> OTHER I <br /> OTHER t <br /> Deiiv ed <br /> g Issuance Date Mailed <br /> Received by Date <br /> Receipt No.. Permi[No- C 95 <br /> k..' w <br /> -� APPLICANT—RETURN ALL COPIES Till ENVIRONMENTAL HEALTH.PERMITISERVICES _ <br /> 1fi01 E.HAZELTON AVE.,P.O.Sox 2099 STO KTON, <br />