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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 / 1 <br /> LIQUID WASTE <br /> Application is hereb made to carry on business in the jurisdictional area-of the San Joaquin Local Health District <br /> rn Business Name (DBA) ✓ Address 4 F R <br /> aOwner d Gi L C_�-12 Address. .. a <br /> L) Firm Partners, Addresses and Telephone Numbers <br /> / <br /> a Business Telephone No. �. Emergency Telephone No. <br /> Contractor Licence No. eia 2 <br /> Applicants Name (Print) ,�1 f ! �LLi _ Title Date 9�0"r k"I <br /> Please check Applicable Category (1-7)and Fill in the Required Informatlon <br /> 1. ❑ PUMPER VEHICLE'PERfMIT REGISTRATION (FOR EACH VEHICLE) + <br /> For July 1, June 30, 19w- - 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: ❑ POMPER YARD i <br /> t <br /> For July 1, June 30, 10"— <br /> No. <br /> 9No. of Vehicles Stored <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. j <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Address PTIC TANK ❑ F <br /> CESSPOOL �EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ,. )j I <br /> ❑ PERMANENT 0 TEMPORARY ❑,NEW f. ❑ REPAIR �Q_OTHER._,L__ <br /> 5. E CHEMICAL TOILETS For July 1,-June 30, 19 1 <br /> :Type,Construction Disposal Site <br /> No. of Units Equipment Storage/Gleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, --June 30,-`19 <br /> Operator'Name .ar f f• <br /> - Where Certified <br /> Plant Location <br /> Plant Capacity -� t No. Units Served R ; <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 'K, <br /> " * $ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,, -.❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. f `" <br /> F } <br /> hereby certify that 4 have -e repared;this application and that the work will lie done in accordance with San Joaquin County <br /> ordinances, state laws;and rules and re`gul ions of the San.,Joaquin Local Health District. <br /> APPLICANT'S SIGNATUREX <br /> It <br /> 1 3 ' <br /> a <br /> FOR-DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ! ❑ PER SITE 1 EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Y. <br /> REMIT <br /> BASE EXPLANATION " REMITTAN i \AMOUNT DUE CHECKED <br /> DATE PAT REMITTED AMOUNT a:, <br /> o- <br /> FEE } a .1 4 A <br /> # _ <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY - .. s _ °' 4 <br /> OTHER <br /> e a SS <br /> �•«---OTHERS.. •n. rr-- - rte- •- �} rc.+ .—w:o ..-a.:a-,# ..., ,.�. <br /> Received by Date Receipt No. Permit No, Is uance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201•' 4 <br />