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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> A k ' . APPLICATION .11 <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 /> U)Business Name (DBA) C Address + <br /> aOwner (A �L f� Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> m Business Telephone No. P���0"] Emergency Telephone No. <br /> Contractor Licence No. Ob <br /> L Applicants Name(Print) ��' 1 Title ESTI h4 A'•• Oft Date77—IS,--1B 1_ <br /> Please check Applicable Category (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., Cdlbe) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> ltquipment.Parking-Address t i <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> Na- of Chemical Toilets Stored r <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Lo ation Test Date/Time I <br /> 4. L� SANITATION PERMIT -Li <br /> ' a <br /> Job Address/Locat}'on ' �rt� 7 e_-wPd-;0_) <br /> Ow er __ ��< 11St. Address�� 7�L'k Mzl& C-77- ��x � <br /> L7 SEPTIC TANK ❑ CESSPOOL BILEACHING FIELD 21SEEPAGE PIT ❑ PAC AK GE PLANT <br /> 21PERMANENT ❑ TEMPORARY BINEW REPAIR ❑ OTHER Tfl <br /> 5. ❑ CHEMICAL TOILETS For July 1, -,June 30, 19 t <br /> Type Construction j Disposal Site <br /> No. of Units .- ' °Equipment Storage/Cleaning Location(s) ; <br /> 6. ❑ PACKAGE TREATMENT PLANT *F'or JuIY41-, -June 30,-19 ". <br /> Operator Name y — Where Certified <br /> Plant Location �` <br /> Plant Capacity_— No. Units Served <br /> 7. ❑ LAUNDRY For July;l,t June 30, 19 <br /> SIZE: ❑ Less Than;1,000 Sq. Ft., ❑ More Than 1,000 Sq rt. <br /> ❑ DRY GLEANING,Chemicals Used/Amount/Mo. + <br /> I <br /> s <br /> I hereby certify that I hav prepared this applicafloq and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws rules and r lations a San J aquin?Local Health District. w <br /> APPLICANT'S SIGNATURE t: <br /> ' n <br /> FOR DEPARTMENT USE ONLY r i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PERSITE — ❑ EACH - ❑'January,1 &Received By January 31 I ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION r' BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> / DATE DATE REMITTED AMOUNT <br /> EEE IL a- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> b _ <br /> OTHER <br /> - s <br /> Received 6y Date Receipt No. Permit No I suanc ate v Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />