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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 /> ENVIRONMENTAL HEALTH PERMIT <br /> r' LIQUID WASTE <br /> Application is her y made to carry on business in the jurisdictional area;of the San Joaquin Local.Health District <br /> ,F Business Name (DBA) 1(11(`l o7 _ Address Y v <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers ., <br /> 916 <br /> Business Telephone No. __ � '� Emergency Telephone No. <br /> -Contractor Licence No. �- } <br /> Applicants Name (Print) r Title !�+�'�� Date <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 o <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. License Renewal No. _ S <br /> Capacity r Gal.",INeighks 8 Measures N0. <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 r , <br /> R.S. or R.C.E. Name -k - _ R.S. or R.C.E. No. q <br /> Test Location r� ` Test Date/Time - <br /> 4. ❑ SANITATION PERMIT '23 } _ <br /> Job Address/Location W /rJ fT/G e <br /> Owner Address <br /> EPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT �. <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site 3 <br /> t c <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -Jbne 30, 19 f <br /> Operator Name -'1 ^ " Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served R` <br /> 7. El LAUNDRY For July 1, -June 30, 19 ; <br /> SIZE: ❑ Less Thar' 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Use&Amount/Mo. <br /> ..i'v -4,..... o- .T ai}.„LYe �.+ �'�prr �n�F . ..+w.. <br /> - I hereby certify thaLitave prepared this application and that the work will befdone�imaccord�nce with San Joaquin County <br /> ordinances;state laws, and rul1es_and r ulatio sof the S n-jooaquin Local Health'District. <br /> APPLICANT'S SIGNATURE y <br /> X ' <br /> FOR DEPARTMENT USE ONLY <br /> r Fee IS Due: ❑ ANNUALLY 0.PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> IREMIT <br /> ­"4"BILLNVG REMITTANCE �$ <br /> BASE EXPLANATION s DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION T <br /> PLUS s <br /> PENALTY # <br /> OTHER - } + <br /> OTHER v <br /> S.-"�:-' _--..q...-,y.�. .�...�..�...-�.�,..w��.. ,«.�...,...•+..� .7-.-'•.-.,+o-.f.`--•. ....=.3;--,- - ,rte �. <br /> Receivcd,by Date Receipt No. Permit No Iss ance Data Mailed Delivered <br /> ° APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />