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i t ApplicMions Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ~ APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> w- a•„w,. '~ <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE ` I <br /> `e+f- <br /> Applicati -hrerreby a to carry on busi esis�in the jurisdictional area of the San Joaquin Local He thh Distrl <br /> Business NaAme (DB`A� /'1 C3/b.'�.�0>OT�� �.c �1f 1G E_ / Ad_dress_ _ - Z27 Si �✓�����+�r <br /> aOwner—h n r _w 1 G// _- Address <br /> J Firm Partners, Addresses and T�eIJ how N m`bers c�1 <br /> CL Business Telephone No. 7� s7 �/6 Emergency Telephone No. <br /> Contractor Licence No. <br /> �Applicants Name (Print) Title Date—3 4, <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) a <br /> For Juiy 1, June 30, 19 Disposal Sites Q <br /> Description(Make/Yr., Color) 1!} <br /> Serial No. CAL, License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address 3 <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> p 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 Location Test Date/Time <br /> 4. )<SANITATION PERMIT f� /L <br /> Job Addre / ocation <br /> i Owner Address-' O%j <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT” <br /> PERMANENT ❑ TEMPORARY ❑ NEW `- XREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 4 Where Certified ' <br /> i _ <br /> I 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 hereby certify that I ha!a4 repared this application and that the work will be done in accordance with San Joaquin County <br /> f ordinances, state laws, les and regul ions of thp San Joaquin—Local Health District. <br /> APPLICANT'S SIG A RE X - <br /> i <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY_ - ❑ PER UNIT © PER SITE El EACH ,❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ - REMIT <br /> . BASE EXPLANATION DATE DATE REMITTED - AMOUNT DUE CHECKED <br /> f AMOUNT <br /> FEE <br /> LESS J L `� F <br /> PRORATION ! <br /> PLUS ) <br /> PENALTY; <br /> ) <br /> OTHER i <br /> OTHER <br /> 2-- (� a <br />� ~Received by Date Receipt No- Permit No. Issubince Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKT IY-CX'95201 <br /> y <br />