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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> �P.PVCAMN <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> Q MENTAL HEALTH PERMIT ' <br /> C [ / �� # .. ENVIRONMENTAL LIQUID WASTE <br /> Applicatiamis hereby made to carry oss in the'urisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA)I&CLuLr�6 2_,J,. �� 'Z� AddressLM <br /> F <br /> z Owner \14M Ick. - AddressZ I I <br /> as ,...... <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. e9 Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> L Applicants Name(Print) + Z Title • t" Date _ <br /> Please check Applicable Category (1-7) and,Fill in.the Required Information �, I; t t. <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. 1 CAL. License Renewal No. ' <br /> Capacity Gal., Weights & Measures No., 1 1 <br /> Equipment Parking Address '+ <br /> 2. 11 PUMPER YARD - <br /> For July 1,1 June 30, 19 <br /> No. of Vehicles Stored _ <br /> No. of Chemical Toilets Stored �� `_t­ <br /> 3. PERCOLATION TEST i � J i pr t O <br /> R.C.E. Name r r 1 1 .Ft, .C.E. No. �Q <br /> ` I ti o �r a Test Date/Time I <br /> Test Location 4 Z Y4 i e-hha_%k <br /> _ ' P�1 B2--l k <br /> 4. 0,SANITATION PERMIT - Q <br /> Job Address/Location <br /> { <br /> Address is <br /> Owner 4- s - ❑ r <br /> ❑ SEPTIC TANK � CESSPOOL ❑ LEACHING F1EL.D ;SEEPAGE PIT PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑'REPAIR ❑ OTHER <br /> .5. ❑ CHEMICAL_TOILETS F r July.1; -June 30, 19 <br /> Type;Construction )! � Disposal"Site <br /> No. of Llni`ts;. 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 f No. Units Served <br /> 7. ❑F LAUNDRY For July 1, -June 30, 19 <br /> .SIZE: t ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000{q. Ft. r .¢�- <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> ,I hereby certify that I have prepared th' plication an hat the wor ill be donen accordance with San Joaquin County <br /> ordinances, state laws, gulations oft a San Joaq ocal Health District. <br /> APPLICANT'S SIGNATURE X ! " <br /> FOil DEPARTMENT_-USE ONLY <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE[ EACH�4 C]+January 1 &'Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT ' <br /> BASE EXPLANATION BILLING �+.�. .+•-REMITTANCE $ AMOUNT DUE CHECKED <br /> -+ ,DATE- DATE REMITTED -' AMOUNT <br /> FEE <br /> LESS t <br /> PRORATION %_11%, 4. <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received byate Receipt No. Permit No. Issuanc Date Maiied Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMtATAL HEALTH PERMIT/SERVICES w 16011 E.HAZELT vE.,P.O.ao■20119 STOCKTON,CA 95201 <br />