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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 /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> wBusiness Name (DBA) MaDona l d SeT)fi n kr Ra ckhnP v Address <br /> i Owner- Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 931 —0 4w9 7 - __ Emergency Telephone No. <br /> Contractor Licence No. Y <br /> Applicants Name (Print) T R ManonLd Title Cl1.rYl pr. 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, -7 June 30, 19 Dlsposal-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. ❑ PERCOLATION TEST f <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location = I Test Date/Time <br /> 4. ❑ SANITATION PERMIT !. <br /> Job Address/Loc ion Q� <br /> Owner Address <br /> 11 SEPTIC TANK ❑ CESSPOOL E] LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW � REPAIR ❑ OTHER G <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 C" <br /> Type Construction L Disposal Site <br /> Equipment Storage/Cleaning Location(s) <br /> No. of Units t <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., I ❑ More Than 1,000 Sq. Ft. t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 1 <br /> . F x <br /> I herebyicertifythat"l have prepared this application'and that the work will be'done in accordance with San Joaquin County <br /> ordinances, state law"and-rlesand reg4gflns of the San J aquin Local Health District, <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> t Fee Is Due: ANNUALLY _ ❑ PER'UNIT ❑ PER SITE.." ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ~I <br /> _r") REMIT <br /> T ' BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> uc <br /> FEE CA <br /> f 7V <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER y ;k <br /> OTHER <br /> Received by S Date Receipt No. Permit No. IsluanclB 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 />