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-.Applications Will Be Processed When Submitted Properly Completed. Be Sure.To SIgnThepplication. ��- <br /> _ ' -APPLICATION <br /> (For Non-Transferable, Revocable,and Suspenda�b e) <br /> _ ENVIRONMENTAL HEALTH PERMIT . - - SEpTAGE . <br /> 11.191.11110 WASTE � ""."_. � <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ' y Business Name{DBA) r G Address s�ZJ <br /> a Owner juGGL:J�,"' Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> L Business Telephone No. t5�7f�/ � Emergency Telephone No. <br /> Contractor Licence No. �l h <br /> _<°Applicants Name (Print) Title _A461� YDate <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 <br /> r Description(Make/Yr., Color) <br /> f Serial No. CAL. License No. CAL. License Renewal No, <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address ' <br /> 2. ❑ PUMPER YARD <br /> I For July 1,_ June 30, 19 ' <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> r 3. ❑ PERCOLATION TEST _ <br /> f R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> TestLocation Test Date/Time <br /> 4. :❑ SANITATION PERMIT. .., <br /> job Address/Location a t��YVGI�b I�A/YFplr! C%`� <br /> Owner .� Addrf 'v <br /> ess <br /> 0-�9'EPTIC TANK ❑ CESSPOOL EACHING FIELD ❑ SEEPAGE-PIT Q.,P_ACKAGE_PLANT..,.... �. <br /> 07 PERMANENT ❑ TEMPORARY ❑ 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 Locations) <br /> r 6.1.0 PACKAGE TREATMENT PLANT'For July'l,'-June 30, 19 <br /> Operator Name - - "` w �= - Where Certified <br /> Plant Location . : <br /> i Plant Capacity No, Units Served F <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ;e ` <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1-,'000,S4—Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> s 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 an recwlations <br /> oftheSan Joaquin Local Health District. <br /> € ` <br /> APPLICANT'S SIGNATURE X �• 1 *- <br />( <br /> a A <br /> FOR-DEPARTMENT-USE ONLY r <br /> a - <br /> Fee-is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ uary t &Received By January 31 ❑ July 1 &Received Sy July 31 <br /> _ RE IT <br /> BASE - EXPLANATION " BILLING RE NCE '� $ AMOUNT DUE CHEC ED e. <br /> DATE ' .DATE REMMII`TTED J� AMO NT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> V , <br /> a OTHER – } <br /> s - OTHER <br /> w Received by r - .Date Receipt No. Issuance Issuance Date Mailed Delivered <br /> - � APPLICANT—RETURN ALL COP�TO._-..ENVIRONMENTAL HEALTH-PERMIT/SERVICES ,� 1601 E.HATELTON AVE.,P.O.Boa 2009 STOCKTON,C 95201 <br />