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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> i <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) / f <br /> I ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is qereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) cl _ <br /> F Address <br /> t. a Owner _�_7��� ���� Address <br /> j Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. a:1 <br /> Contractor Licence No. �2-j.�tL2_ <br /> L Applicants Name (Print) Title <br /> Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> l 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />[ For July 1, June 30, 19 Disposal Sites <br /> r Description(Make/Yr., Calor) <br /> Serial No. <br /> CAL. License No. CAL, Licc7se 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. ❑ SANITATION PERMIT _fit <br /> Job-Address/Location <br /> Owner {' Address —- .- �- BGG d z <br /> Z"SEPTIC TAM( ❑ CESSPOOL ' L1=ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ` I <br /> ❑ PERMANENT ❑ TEMPORARY`; n❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -Ju e'30, 19 <br /> Type Construction Disposal Site P <br /> f No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 # <br /> Operator Name 4 i.Where Certified r <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000=Sc"Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. s <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County t <br /> ordinances, state laws, and rules and regulati s of a San Joa ri Local Health District. 1 <br /> APPLICANT'S SIGNATURE X- <br /> x <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH ❑•' <br /> : January 1 &Received By January 31 El July 1 &Received By July 31 <br /> BILLING +• EM1iIITTA REMIT <br /> -BASE EXPLANATION $ <br /> DAT DAREMITTED AMOUNT DUE CHECKED ' <br /> T ' <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> . f <br /> OTHER �- ...`_-.`• - . <br /> i <br /> OTHER - <br /> "M 757 <br /> Received by Date Receipt No s t�-Permit'No. I Suanc Data Mailed Delivered f <br /> APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL-HEALTH-PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />