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Applications Wli rocessed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> SEP 7 1979 APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) 4 47 � �j <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SAN JC�AQUIlNLUCAL LIQUID WASTE IIII <br /> H i HioR ��149-Tade to carry on business in the jurisdictional area of the San Joaquin Lo al Health District P <br /> nBusiness Name (DBA) Address—/ ?C _ <br /> aOwner �' Address Cr l� <br /> Firm Partners, Addresses-and Telephone Numbers _ a <br /> 4 Business Telephone No. — ���=8' �� Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) ? Title Date <br /> Please check Applicable Category (i 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) I <br /> Serial No. Ii CAL. License No. CAL. License Renewal No. t <br /> Capacity J9Gal.,Weights &Measures No. <br /> Equipment Parking Address I <br /> 2. ❑ PUMPER YARD ip <br /> For July 1, June 30, 19 ' <br /> No. of Vehicles Stored II <br /> No. of Chemical Toilets Stored I� <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location I� 'Test Date/Time- <br /> 4. �R SANITATION'PERM�S Z I� � , -7 <br /> Job AddresLocation `ff'� <br /> Owner — 0-n Address 4. <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �{ <br /> Type Construction II Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) III <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 `] <br /> Operator Name Where Certified 1 <br /> Plant Location r �� <br /> Plant Capacity No. Units Served 1 <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> I <br /> SIZE: ❑ Less Than 1,000 Sq. Fti., ❑ More Titian 1,000 Sq. Ft. ' o <br /> ❑ DRY CLEANING,Chemicals"Used/Amount/Mo. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I <br /> ordinances, state laws, an les and regulations of the San Jo quin Local Health District. <br /> APPLICANT'S SIGNATURE X N <br /> I� <br /> 1. FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY i❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE '`` tATI.ONBILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEETLESS :IPRORATION <br /> PLUS PENALTYOTHER <br /> if. <br /> OTHER I� <br /> Received by 'Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT RETURN ALL COPIES TD: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />