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UV.1U 'Applicaations Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> � % LOCAL APPLICATION <br /> �k�3`^ `" (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> w ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is h reby made to carry n business in the jurisdictional area of the San Joaquin Local Health District <br /> .n Business Name (DBA) '� C• Address��; � s _d Wo c-, • <br /> z Owner 4frku: [nI S C,r Address ! /1 O <br /> Firm Partners, Addresses and Tele one Numbers ' <br /> aBusiness Telephone No. b Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title C)fr fTlA.T Date a <br /> S <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 /> Description(Make/Yr., Color) <br /> Serial No. CAL, License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <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 f n <br /> 3. ❑ PERCOLATION TEST VJ <br /> R.S.or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Da ime <br /> 11 SANITATION PEBMIT <br /> Job Address/Location (f ��I� 1 1w <br /> Owner G (AIhress ver G d <br /> ❑ SEPTIC TANK ❑ CESSPOOL XLEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLAN <br /> PERMANENT ❑ TEMPORARY ❑ NEW XREPAIR Ili OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 /a( <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 - <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 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - <br /> hereby certify thaLlhave prepa th' application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state land rule r lations of t an JAoaq Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> W ©�7 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due., ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> BILLING REMITTANCE $ REMIT . . <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> O <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS �— <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Iss ante ate M ed Delivered , <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE., .Box 2009 STOCKTON,CA 95201 <br />