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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on busi ess in the jurisdictional area of the San Joaquin Local Health District <br /> m Business Name (DBA) .�r H. oo i*AZR>sh+ �v�o V - Address , 0. <br /> If <br /> IF- Owner Address <br /> 9 <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. _ y Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> L Applicants Name (Print) � Title 's7e�' Date 4eft& i <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 <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. 0 SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> 54 SEPTIC TANK ❑ CESSPOOL 'A LEACHING FIELD A SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY R NEW ❑ REPAIR ❑ OTHER ~ <br /> S <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 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 /> B�fB 41 perlarmanre of the wnik for which this permit is issued,l shall not employ any person <br /> 4n SU0 man as t0 . , <br /> f�%'Oiytlk fwit fitrrn or suA t,'rsn'r��;c'.tirkl g, rt�t a F._Y wi. '°�c `�rh^. ,r, A cel tity that in the peliormance of the work for which this permit is issued,i shall <br /> I.�.p.f4�f f7$fbfTT16 S!}b�QCf t0 N6rl(i711i S Fty)F ai`ia tLi31L(a4-�6'1 xc�.G.�...1.. <br /> 1 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 and regulations of the San Jo Local Health District. <br /> 4001 <br /> APPLICANT'S SIGNATURE X —, <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMDUNT DUE CHECKED <br /> AMOUNT <br /> FEE 'eF 's 4s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY � I <br /> OTHER ✓c I"` <br /> IF <br /> OTHER <br /> Received by Date Receipt No. PerrniT Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 16131 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />