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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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> 3 LIQUI©WASTE <br /> Application is h reby mad(.,_.tQ carry on business in the jurisdictional area of the Sanaquin Local Health District <br /> H Business Name (DB ) ', ,�, /����'�� Address .J� c t11_C;s✓� <br /> z OwnerG Ci Address cI+�L y <br /> J Firm Partners, Addresses and Telephone Numbers ) <br /> IL Business Telephone No. *rbb J_ Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) 4_.z, Title gf24.cJ /t/ Date — 3_0 <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> l <br /> For July 1, June 30, 19 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 /> r = <br /> . For July!1, - June 30, 19 <br /> No. of Vehicles Stored 7 <br /> No. of Chemical Toilets Stored 1 .. <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name` R.S. or R.C.E. Not 4 3_ <br /> Test Location Test Date/Time } `' <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location ! 7 fjf� Kms ® • jam SCJ y- <br /> Owner "7" Address <br /> EPTIC TANK ❑ CESSPOOL 2 LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT <br />` ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR <br /> El OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 b a <br /> Type Construction Disposal Site ' µ <br /> No. of Units Equipment Storage/Cleaning Location(s) J+ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name . <br /> P Whe�e_Certified_ <br /> Plant Location <br /> 5 <br /> Plant Capacity r No. Units Served , <br /> 7. ❑ LAUNDRY For July 1, -June 30, 197'- <br /> SIZE:.- ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,060 Sq-Ft »' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> 1 hereby certity that l have prepared this application and that the work will be done in accordance with San Joaquin,County <br /> ordinances, state laws, and rules and r uiatio of the San Joaquin Local Health District. a <br /> y <br /> t - t <br /> APPLICANT'S SIGNATURE X �- ' i <br /> i <br /> f FOR DEPARTMENT USE ONLY ' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT:._:��. PER.SITE,, ,,Q_EACH ❑ Jarivary 1 &Received_By-January 31 July 1 &Received ByJuly.31 ' <br /> ` BILLING REMITTANCE $ REMIT <br /> E BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> - _ - AMOUNT <br /> FEE Li 15 <br /> LESS l <br /> PRORATION ' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER +4 ;.na ,4 �'+�1', w .�• -�'. -'�'� <br /> Received by Date . Receipt No Permit No. rsuarick Date Mailed De ered <br /> - APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 i <br /> V Air" <br />