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-� Applications Will Be Processed When Submitted Properly Compteted. Be Sure To Sign The Application. ; <br /> APPLICATION <br /> (For Non-Transferable,-Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT D� <br /> LIQUID WASTE 10 1 - 470 1 <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District j <br /> rn Business Name (DBA) L Address <br /> ca <br /> z Owner t"`'p�-. Address /po� c c. / ••B .moo n ��rs <br /> J Firm Partners, Addresses and Telephone Numbers <br /> as Business Telephone,No. Emergency Telephone No. <br /> a 'i. <br /> Contractor Licence No. �C! <br /> L Applicants Name (Print) ����- Se Title cD wiz C r Dater <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 4 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored l , <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST I <br /> R.S. or R:C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. WSANITATION PERMIT <br /> Job Address/Location _ o r 8 Ste"���s C��'r t. - S 7L t-�`— <br /> Owner �� � 5C �� Address <br /> SEPTIC TANK ❑ CESSPOOL 21LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW,, ❑ REPAIR ❑ OTHER <br /> m <br /> 5. El CHEMICAL TOILETS For July 1, -June 30,^19 <br /> Type Construction %� Disposal Site <br /> 4, J <br /> No. of Units ,Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENfPLANT'`rFor 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. r <br /> ❑TDRY CLEANING, Chemicals Used/Amount/Mo. <br />`. 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 9nd regulations'of the Sa - aquin Local Health District. <br /> 'APPLICANT'S SIGNATURE X .���,,"`� <br /> T A j <br /> .t <br /> ' FOR DEPAR MENT USE ONLY i <br /> ( Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ' ❑ EAAH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEEqS <br /> -� <br /> LESS " <br /> PRORATION - <br /> i <br /> PLUS.. <br /> PENALTY <br /> OTHER <br /> AAA <br /> s I <br /> OTHER <br /> Received.by Vale Re6eip No- Permit No. Issua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES '1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />