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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatioq is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> U) Business a (DBAX__ -- --- - --- - --- - - Ad ess - - ----- -- ---- --- -- - <br /> z Owner r4^�I erg G.9�2 e�S�'�! <br /> --. _ - __-. Address.._ Q�-. - �W- ' '_ --------- ----- -- - <br /> J Firm Partners, Addresses and Telephone Numbers _ -----__._.______ <br /> - -- -- <br /> aBusiness Telephone No. .____-__.- ----- -._____ Emergency Telephone No. <br /> Contractor Licence No. _ <br /> < Applicants Name (Print) _ /T iATZ' TST�^Ka L�Y�'16t17C N �J <br /> L - - Title -- "�L - Date----L- — <br /> Please check Applicable Category (1-7)and Fill in the Required Information 7 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) /44: ,ws7 e1q, S63.15.S <br /> For July 1, _June 30, 19 . -- Disposal Sites ----------_-.-_--_--- -_-_-_ _. __.---..------.----___-- <br /> Description(Make/Yr., -__--_- <br /> - --------- ----- - <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 i,_._____-__ June 30, 19 <br /> No. of Vehicles Stored --_.-_---------__._._-----------------------__-.-- <br /> No. o Chemical Toilets Stored <br /> 3. ERCOLATIIQNT �r t i„ ►.�- - ._�-__ <br /> R.S. or R.C.E. Nam �[> G rfo�ne J f/�! T•�� R.S. or R.C.E. No. �r Av •9� <br /> Test Location If.—a-3 _ Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location ------------- ---- --- ---- - --- -- - -_ __... ..._._. - --------------- ----------- <br /> Owner <br /> ❑ SEPTIC TANK CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ,,-"b 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. <br /> ocations).-__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 red this Aofan <br /> hat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an es anb4egulJoaquin Local Health Distri t. <br /> APPLICANT'$SIGNATURE X - -__ �!X V ' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> - --------- -- _—_ REMIT------- <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT pUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Q_:;I <br /> ---- ------ <br /> -------- ---------- — <br /> LESS — - --- <br /> PRORATION <br /> PLUS <br /> PENALTY f <br /> OTHER <br /> OTHER <br /> Reyeived ba _ Date Receipt No'- I Permit No. Issuance Date Meiled — Delivered — <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAIELTON AVE.,P.O.Box 2009 STOCKTON,CA 9501 <br />