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nN�+n\.au�ua r•m pc ri,�•,caacu wncu Ju4nnucu rivNc�ir •.vu\r,c•cu. uc .awc \v.a\yn •nc•.rr.w.••w,.. �� 7 ` �� ' <br /> M•S� 9 2 0Z APPLICATION <br /> -(For Non-Transferable, Revocable, and Suspendal5Te) SEPTAGE � <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made t9 carry on business to the jurisdictional area of the SarlJoaquin Local Health District n <br /> H Business Name (DBA) e'=� rti�+�� �i _g_�:, ' Address _9:Z3 W a JT. { fri � 757.4-e' <br /> iOwner "•f�� /.a '. _ Address La"t- CLQ.. ?E� <br /> J Firm Partners. Addresses and Tele hone Numbers <br /> aBusiness Telephone No. .:�� 1 v' _ _ Emergency Telephone No. t 4" 414 — ---_ <br /> Contractor Licence No. <br /> a Applicants Name (Print) Date Title G•�• _ <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., Color) <br /> Serial No. _ _ CAL. License No. CAL. License Renewal No. <br /> Capacity - Gal.,Weights & Measures No <br /> 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. Iff PERCOLATION TEST <br /> R.S. o4gE Name `I I �Y j'rs= A R.S. o C.E1No. 6117?1 _ <br /> Test Location - 0769 5/ C. Test Date/Time - <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner - - _ Address <br /> ❑ SEPTIC TANK ❑ C119SPOOL ❑ 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 _ _ 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 /> 7. ❑ LAUNDRY For July 1, -June 30, 19 _ <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 that I have prepared, this a I and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulati t e San Joa in Local Health District. <br /> APPLICANT'S SIGNATURE X ----"� - --- -- <br /> FOR DEPARTMENT USE ONLY <br /> Fee. Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> __7REMIT <br /> BILLING REMITTANCE $ <br /> AMOUNT DUE CHECKED <br /> BASE EXPLANATION r♦ <br /> DATE D REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION -- -—_ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Reserved by^ Date Receipt No Permit No - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />