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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> _ - (Far Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati f!s hereby ade to car ,on businelss1F the jurisdictional area oft sn Joaq#Loa Health D,'Istric / f <br /> H Business Name (DBA) `L17 �fG/� i<Igi' ` Address— -✓ �� <br /> aOwner Address <br /> Firm Partners, Addresses and Tjalephone Numbers <br /> zi <br /> 0.a Business Telephone Na. .5 �� Emergency Telephone No. f"f <br /> Contractor Licence No. - l <br /> L Applicants Name (Punt),/&0t 1> Title4' '• Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information r ~ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE), <br /> For July 1, June 30, 19 17isposal;$it s'i 'I V. 'AA <br /> �. <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No.s CAL. License Renewal No. <br /> a t ' <br /> Capacity Gal., Weights & Measures NO. •" = � <br /> Equipment Parking Address <br /> ❑ PUMPER YARD <br /> 2. r <br /> For July 1, June 30, 19 { 4 4 w > <br /> No. o1 Vehicles Stored <br /> No. of Chemical To ets,Stored <br /> ,. <br /> 3. ❑ PERCOLATION TEST: <br /> t s es• <br /> R.S. or R.C.E. Name - ! -R.S. or R.C.E. No. <br /> Test Location Test bate/Time <br /> Q. ❑ SANITATION PERMIT <br /> Job Addcis/Location <br /> Owner, fit S4C it ht t =� Address i tyle i ) <br /> ❑ SEPTIC TANK ❑ CESSPOOL; { [R`LEACHING FIELD 8--SEEPAGE PIT ❑ PACKAGE PLANT g � <br /> O ERMANENT ❑ TEMPORARY--y MN EW 1 0 REPAIR ❑ OTHER <br /> 5. E] CHEMICAL TOILETS For July 1„ une 30, 19 y11x <br /> Type Construction Disposal Site -------t # <br /> No. of Units Equipment Storage/Cleaning Location(s) �� <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 t <br /> Operator Name here Certified % — - <br /> Plant Location G' tl�`, # 3 <br /> Plant Capacity i No. Units 5ervd �e <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19— <br /> SIZE: <br /> 9 SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.'Ft. l <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> '� 4L s <br /> 1�(-,TAC . 'F i!r race C.I okI ! t=? <br /> I hereby certify that I have pr ��nd <br /> d this applicationInd that the work-will be dohe in accordance with San Joaquin Counity <br /> ordinances, state laws, and Ieregulatib s-of the San Jsaqui `Coral Health District. i r <br /> APPLICANT'SSIGI�IATURt=-X �� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT © PER SITE I ❑ EACH --❑ 4anuary-1'&Received By January 31 ❑ July 1 &Received By Ju{y 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS j s <br /> PENALTY <br /> OTHER S <br /> OTHER ---��^- <br /> ri <br /> Received by Dath - Receipt No. Permit No. Issuance 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 />