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e: 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 /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) Address _r • Ga A_) <br /> I Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 44e,6' m7 Emergency Telephone No. <br /> Contractor Licence No. — 1f3 <br /> L Applicants Name (Print) Title M A�r,O�-Date <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 t' 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 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored r <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. M`';NITATION PERMIT L�T � +sA�.�G� AA0/770k) <br /> Job Address/Locati n <br /> ,Ow, ner•_ 5 /c.1 Address 7 <br /> ASEPTIC TANK.� ❑ CESSPOOL O'CEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> Q l ERMANENT ` ❑ TEMPORARY 91'I11EW ❑ REP IR BOTHER —1. KVX kD ���J>5 <br /> S. 11CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction __- Disposal Site' S) 0. <br /> No. of Units Equipment Storage/Cleaning L a n{s) <br /> 6. ❑ PACKAGE TREATMENT PLANT 4.,For July 1, -June 19 N , <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Univ d <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 Ma <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Th 0 Sq. Ft. r <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MVJ /W.I. . <br /> # <br /> i <br /> I hereby certify that I h prepared this application d that t y�ork will be done in accordance with San Joaquin County <br /> ordinances, state laws les aild r lations of an J in Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY *- <br /> Fee Is Due:-"EP ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT OUE CREMIT <br /> HECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS - I <br /> PRORATION t <br /> PLUS <br /> PENALTY " <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. jssuanc6 Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMiTISERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />