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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign-The Application. <br /> APPLICATION <br /> . �_ ... T (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE ©Po -- 5-yo --0,_- <br /> Application i5•"ereby madye�o carry on business in the jurisdictional area of the San Joaquin L cal Health District <br /> Business Name (DBA) f �� Address ��� <br /> z Owner -� .v�_ Address �U a <br /> a : <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No, / r.�� - Emergency Telephone No. <br /> ContractorLicence No. <br /> LApplicarits Name (Print) Title. } Date ' <br /> Please check Applicable Category (1-7)andII"in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) i <br /> For July 1, June 30, 1"9 -- -Disposal Sites <br /> Description(Make/Yr„ Color) -� <br /> Serial No. CAL. License No. CAL. License Renewal No. J <br /> Capacity Gal., Weights &Measures-No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, Y June'30, 19 W <br /> No. of Ve_hicles•Stored i <br /> No. of Chemical Toilets Stored v' <br /> 3. ❑ PERCOLATION TEST =,c <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location ✓� ( S �� rr �G�-��_ ] <br /> Owner — L 0 L-e-Z� -2- <br /> �1 f ��f ma c_' Address <br /> t,_.< <br /> SEPTIC TANK . CESSPOOL ©`LEACHING FIELD ®-SEEPAGE PIT ❑ PACKAGE PLANT <br /> Q PERMANENT ❑ TEMPORARY P EW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 i <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 8. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t <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 5q. Ft., More Than 1,000 5q. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I ' <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 ru es".bnd regulations-of the San Joaquin Local Health District.. <br /> APPLICANT'S SIG NATURE X <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 AMOUNT"DUE.. CHECKED <br /> i DATE DATE REMITTED AMOUNT' ' <br /> FEE t orf y } (`� 00 <br /> LESS v <br /> PRORATION /LGLrl�rr �� 4 <br /> / yf <br /> PLUS le- /���� -11..—K fis <br /> PENALTY �" <br /> OTHER ' <br /> .OT,HFR <br /> Received by Date Receipt No. Permit No. msuanco DateMailed Delivered <br /> s <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> v � <br />