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Applications Will Be Processed When Submitted ProperlyCompleteo. 13L-Jure rW �,y,. •;•� ^rr• <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) I SEPTAGE <br /> 4 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE "- '• <br /> Application is he by made to carry on business in the jurisdictional area of the San.lo�uin Local Health District <br /> r�U y Address <br /> FBusiness Name (DBA) - <br /> r •Tr��Lo .Address <br /> z Owner �,�-+ - _ ..:.Address <br /> - <br /> JFirm Partners, Addresses and Telephone Numbers <br /> J Emergency Telephone No. <br /> aBusiness Telephone No.. , <br /> Contractor Licence No. Date <br /> Title, <br /> LApplicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information tir <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, ._June 30, 19 - - - Disposal Sites _ <br /> Description(Make/Yr.,Color) <br /> CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address _ <br /> 2. ❑ PUMPER YARD_--.---'.'.`° <br /> - - <br /> - For July 1;"� June 30, 19 ---'-'�'"'�" •� l <br /> No. of Vehicles-Stored <br />' No. of Chemical Toilets Stored <br /> 3. El PERCOLATION TESTWe <br /> . R.S. or R.C.E. No. , <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test,_,L.,oca��Cgri t'. lee- <br /> 4. ILd-ANITATI0N PERMIT <br /> Job Address/Location <br /> Owner Address <br /> '0 SEPTIC TA Kms❑ C_ES 0OLf ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ REPAIR 1:1 OTHER >� <br /> ❑ pERN�ANENT�TEMPbRARY ❑,NEW + a <br /> 5. ❑CHEMICAL TOIhETS For July 1, -June 30, 19 : i <br /> Type Const ction <br /> No�� - Disposal Site <br /> 'r fUnitsf Equipment Storage/Cleaning Location(s) <br /> - • <br /> s ✓ <br /> �6. ❑fPACKAGE TREATMENT PLANT For July 1, -June 30, 19 ft--;•�-�••�"'^ � } <br /> I Where Certified„_ _ <br /> operator Name <br /> ', Plant Location _ - 13 <br /> 1 3 --Na Units Served A-/} Plant Capacity <br /> 7. ❑ LAUNDRY For July 1;-June 30, 19 «.Y -�• - "" "`^ `" , <br /> ' 13More Than 1,Goo' : Ft. { <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 41 <br /> Y�S � <br /> hereby certify that I have prepared this applic on a dhat-the work will be done in'accordance with San Joaquin County <br /> ( ordinances, state laws, and rules and re ation of the'San Joaquin Local Health District. <br /> '4/ <br /> " APPLICANT'S SIGNATURE_X <br /> .FOR DEPARTMENTTUSE ONLY 4 <br /> �. <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT, ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 El 1 8•RecerveRd IµlTuly 31 <br /> k P <br /> "�,.,;.,- ����-•--- �^""``-- '"'"",'BILLING REMITTANCE �'� AMOUNT DUE CHECKED <br /> F BASE EXPLANATION DATE -.DATE REMITTED„�N �;�, �.:g, AMOUNT <br /> 11 <br /> FEE % a t <br /> x <br /> LESS i r <br /> . PRORATION 4 ” <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> I OTHER <br /> Iss nce D to Mailed Delivered <br /> Received by <br /> Date Receipt No. Permi N <br /> 1601 E.HA2ELTON AVE.,P.O.Box 2069. STOGKTON,GA 95201 <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - - <br /> 6, <br />