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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION /) <br /> rti (For Non-Transferable, Revocable,'and Suspendable) J SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT ! <br /> LIQUIo WASTE <br /> Application is he eby ade to carry on business in the jurisdictional area of the San Joaquin Local Health District. <br /> P — Address <br /> Business Name (DBA) <br /> aOwner _ �_!TL�" Address <br /> J Firm Partners, Addresses and Telephone Numbers a - <br /> a14/2 Telephone No. _ � Emergency Telephone No.. ) <br /> a Contractor Licence No. . . _ _ w <br /> Applicants Name (Print) f Title _ ��.� - Date <br /> Please check Applicable Category(14)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 /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal NO. <br /> Capacity Gal., Weights& Measures'No.- t <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 t <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. Na. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMITS ) , <br /> Job Address/Location <br /> Owner �' ' 47 7A ma KE7 <br /> Address <br /> � d <br /> SEPTIC TANK 11 CESSPOOL' - �;-�-LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT „ <br /> ❑ PERMANENT TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 . �. L <br /> f <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s)�' { <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 ^moi <br /> Operator Name r -- Where Certified — <br /> Plant Location <br /> ( No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY .For July 1, -June 30, 19 <br /> SIZE: ❑ Less Thari 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> IF <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo., T <br /> v 9 . .P <br /> f' <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 rules and re ulations of the_Sah'Joaquin Local Health District. <br /> APPLICANT'S SIGNdURE X <br /> —' FOR DEPARTMENT USE ONLY y t <br /> 1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE . ❑ EACH+�� ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 1 - BILLING j REMITTANCE $ - RE <br /> (, BASE EXPLANATION AMOUNT DUE CHECKREMIT ED <br /> DATE ATE REMITTED AMOUNT <br /> _tri Q i <br /> FEE ¢ i i 4 <br /> LESS i <br /> PRORATION <br /> t <br /> PLUS ' <br /> PENALTY _ s' <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss ante Da Mailed Delivered F <br /> ' <br /> 01 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM "1801 E.HAZELTON-AVE.,P.O.Box 2009 STOCKTON,CA 952 1 <br />