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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> i - .-- APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br />` G i4. f7 - Address <br /> y Business Name (DBA) <br /> i Owner� Address <br /> .Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 91 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) <br /> S {'✓C 4' O►' O' Title (�fiV� P 'r Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> r 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 /> t 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 3. ❑ PERCOLATION TEST <br /> II R.S. or R.C.E. Name i R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. XSANITATION PERMIT <br /> Job Address/Locatigp 0-7 �' ; C' <br /> Owner e T 1l'I n mG Koi"fin s Address ---. <br /> SEPTIC TANK D,CESSPOOL „ LEACHING.FIELD ❑ .SEEPAGE PIT ❑ PACKAGE'PLANT <br /> K PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19- <br /> Type <br /> 0, 19Type 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 /> r 7. ❑ LAUNDRY For July 1, -June 301-419 - <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., More Than 1,000 Sq.-Ft.-� ' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify hat I have-prepared this"application and that the work will be done in accordance with-Sa J a in Co <br /> ordinances, state laws, aria ruleIArn regulationsof tie San Joaquin Local Health District. d <br /> APPLICANT'S SIGNATURE XIV <br /> t r s <br /> lr` FOR DEPARTMENT USE ONLY <br /> �~ t- R t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE B EACH ❑_-January 1 &Received By January 31 ElJul 8 Received By July 31 <br /> REM11 <br /> " BILLING (REMITTANCE AMOUNT DUE CHECKED <br /> ti„ BASE} EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> a. <br /> FEE ' <br /> LESS `" <br /> PRORATION - <br /> PWS I <br /> PENALTY <br /> OTHER <br /> I '`OTHER " <br /> R� - <br /> �F <br /> Received by Date _ Receipt Na. Permit No. - Iss ante Date Mailed Delivered <br /> ............� s�..a.,.. . ir, rn• FrwlRnelUFUTAL I-IFAIi PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON CA'95201 <br />