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n/ y Applications Will Be Processed When Submitted Properly Completed. Be Su- To Sign The Application. <br /> E� APPLICATION 1%., <br /> ,44r Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> nz�� 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 /> mBusiness Name(DBA) Address <br /> Owner Address <br /> Firm Partners,Addresses and Telephone Numbers <br /> � Business Telephone No. <br /> Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name(Print) M yJae- Title Cj(g�CaCL'Y Dale ' <br /> Please check Applicable Category(1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) W <br /> For July 1, June 30, 19 Disposal Sites n <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 I 'i <br /> For July 1, June 30, 19 <br /> No..oh Vel{ic(es.Stpted _ <br /> No. of chemical Toilets Stored <br /> 3. []-PERCOLATION TEST _ <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ISS SANITATION PER �T <br /> Job Addres�sy�l�ocauon �� <br /> Owner—J_I1I7 ,9 %e r)/)0) YZ Address <br /> M SEPTIC TANK ❑ CESSPOOL Ii LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ® PERMANENT ❑ TEMPORARY 1211NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site pQ <br /> No. of Units Equipment Storage/Cleaning Location(s) (� <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 r <br /> Operator Name Where Certified 1 <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. FL, ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> _9 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, r dY,(JulleesMan'd'regulaPe s of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X —/ I <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 It Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> �( <br /> FEE <br /> LESS <br /> D <br /> PRORATION S <br /> PLUS / <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> yh <br /> Received by I Date Receipt M. Permit No. Issuance Dal Mailed Delivered <br /> APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON .Goa 2009 STOCKTON,OA 95201 <br />