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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r <br /> APPLICATION <br /> - (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> �- ENVIRONMENTAL HEALTH PERMIT O <br /> -�pM7 * ;4LIQUID WASTE f f 7 <br /> Application is hereb_y made to carry on business in the jurisdictional area of the an Joaquin Local Health (strict . + <br /> .n Business Name (DBA) .4 8 T Address �� • /�Es� �7-�x.� 9.S�Zo ✓ <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and�Telephone Numbers <br /> CL <br /> Business Telephone No.�— '?407 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) s'r G Title T A4,4710 Date <br /> Please check Applicable Category (1-7) nd Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Q <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) J <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. ul <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> t <br /> For July 1, June 30, 19 <br /> 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�Loon Test Date/Time ti <br /> 4. t� SANITATION PERMIT N <br /> Job Address/Location �tJ r Git9• �' � 'r xd s7 � �l <br /> OwnerAeLz !g Address <br /> 11SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW ®REPAIR ❑ OTHER ; <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 % I <br /> Type Construction a Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 4{ <br /> Operator Name Where Certified F <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 /> i <br />` I hereby certify thAhaprepared this application an that the work will be done in accordance with San Joaquin Countyordinances, state lules a regulati of t an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X �{ n <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> yo <br /> FEE � r <br /> LESS <br /> I PRORATION <br /> PLUS ' <br /> PENALTY <br /> OTHER V T <br /> k <br /> I <br /> OTHER <br /> Received by - bate Receipt No. - -' Permit No. - ,issuance to Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL E.;P.O.Boa 2009 STOCKTON,CA 95201 <br /> �� w <br />