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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTneAppncaiTon. " <br /> APPLICATION <br /> (For Non-Transferable,Revocabte,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of.the San Joaquin Local.Health-District <br /> ;". rr ••��;. <br /> OF Business Name (DBA) ` : . Address T <br /> z Owner �) � K' . . ,Address ��J.�X.` 4•ru <br /> a .. <br /> u Firm Partners, Addresses and Telephone Numbers - O� <br /> a Business Telephone No.. <br /> ' h .' 4 Emergency Telephone No. _ <br /> w <br /> Contractor Licence No. t, ate <br /> L Applicants Name (Print)= t2 Y, T•t e,- Y { <br /> Please check Applicable Category,(-1-7),and Fill in the Required Information." <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> �- - ... _ . <br />�. For July f; � - - June 30, 19 '� �--"�--� �- -Dis Posal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity - Gal.,Weights S Measures No. <br /> Equipment Parking Address _ <br /> L 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 i <br /> I No. of Vehicles Stored - <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. - <br /> Test Location Test Date/Time <br /> F� <br /> 4. 0 SANITATION PERMIT I <br /> Job Address/Location Z ��.•. P'/u/45GOZ-G 7e V C <br /> O er 71, <br /> E Address <br /> SEPTIC TANK ❑ CESSPOOL" LEACHING FIELD ❑ SEEPAGE PIT 11 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY �K NEW ❑ REPAIR ❑ OTHER <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 /> 6. El PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> ` Where Certified <br /> Operator Name <br /> r , <br /> Plant Location <br /> Plant Capacity No. Units Served <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 /> w <br /> _ z : <br /> 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 regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X- <br /> FOR DEPARTMENT USE ONLY 4 f x <br /> s <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received'By Jury$1 <br /> ' REMIT <br /> RASE EXPLANATION BILLING REMITTANCE $ .`AMOUNT DUE CHECKED <br /> DATE DATE REMITTED- 'AMOUNT <br /> FEE <br /> LESS <br /> PRORATION •' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 6 J4 <br /> Received by Date Receipt No. Per n No. Issuance D e Mailed Delivered <br /> APPLICANT—RETURN ALL COIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES` 1601 E.HAZELTON AVE.,P.O.Box 2009 STOGKTON,CA 9520 <br /> Pq <br />