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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> APPLICATION <br /> (For Nan-Transferable, Relocable;'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE 1 <br /> Applicatio is hereby made to carry,on business in the jurisdictional area of the San Joaquin Local Health�Dis rict•, , :/ <br /> [ C _ <br /> NBusiness Na.... (DBA /-�[� �<' l C C SQti ' c� wGAddress <br /> z Owner 1 i^ /, _ Address db T <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness.Telephone No. - :Emergency Telephone No. <br /> Contractor Licence No. -T x <br /> Applicants Name(Print) 00r, rJ —�—� � / Title G r' Date T / <br /> Please check Applicable Category(1-7) and Fill in the Required Information y. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I <br /> For July.1, ; - June 30,'19 = <br /> Disposal Sites <br /> Description(Make/Yr., Color) y <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 t ; <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. + <br /> Test Date/Time <br /> Test Location . <br /> 4.-JA SANITATION PERMIT <br /> Job Address/Location G w /�+ o +'✓ <br /> Owner ;! , SC-5 �7IG o Address ' _ � ru r c �o 3 <br /> fi4 SEPTIC TANK ❑ CESSPOOL LEACHING FIELD P SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT 11 TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -"June 30, 19 r»- <br /> Type Construction Disposal Site .f <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> i "Operator Name Where Certified } <br /> Plant Location <br /> Plant Capacity I No, Units Served <br /> 7. 0 LAUNDRY For July 1, -June 30,.19 <br />' SIZE: © Less Than 1,000 Sq. Ft.,. 0 More Than 1,000 Sq."Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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, n�f rules and r�julat•ans of San Joaquin Local Health District. <br /> . I - .. <br /> APPLICANT'S SIGNATURE X <br /> x I[ <br /> FOR DEPARTMENT USE-ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER'UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January,31 ❑ July 1 &Received By July 31 <br /> SEXPLANATION <br /> REMIT'BASE LLING REMITTANCE $ AMOUNT DUE CHECKEDDATE DATE- ;REMITTED AMOUNTFEELESSPRORATIONPLUSPENALTYOTHER. 'r <br /> .OTHER . - - - - _ -, -• -- u ?r <br /> Received 6y Date Receipt Nv. Permit No, Issuance Dat led Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlS£RVICES- 1601 rE.HAZELTON'AYE.,P.O.`Bax 2098 STOCKTON,CA 952D - <br /> f; <br />