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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> P (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application ' reby made to carry on business in the jurisdictional area of the San Joaquin Local Health District I <br /> Business Name { BA) Address— 5 _ �� � �� G � <br /> i Owner Address -,;2 Q :7 SIC, C� e t <br /> a i <br /> J Firm Partners, Addresses and Tele <One Numbers <br /> Ili. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date zoo yJ <br /> Please check Applicable Category (1-7)and Fill In the Required Information i A`EENCE'S S ppC SEV, R SF.Ft'[CE i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Lig„ S0. Lila " S-mck,Ori, Calf. 95205 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) r- <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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. WSANITATION PERMIT <br /> Job Address/Location ¢ v"`' <br /> Owner - Address r r <br /> ❑ SEPTIC TANK ❑ CESSPOOL ALEACHING FIELD SEEPAGE PIT .❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site _ —CA <br /> No. of Units Equipment Storage/Cleaning Location(s) <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., ❑ More Than 1,000 Sq. Ft. ,a <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, an�s regulations of the San Joaqpla Local Health District, <br /> APPLICANT'S SIGNATURE X "P I s'tt I+i i'•'a `f= ER oCa',r!n <br /> }iii { >:f. -.1-3-35 <br /> OAD <br /> FOR DEPARTMENT USE-ONLY <br /> Fee Is Due; ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &ReceivedByJanuary 31 ❑ July 1 &Received By July 31 ' <br /> t BILLING REMITTANCE $ —+REMIT <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> - i AMOUNT L <br /> i <br /> FEELESS <br /> PRORATION � � f CF 1;f i <br /> PLUS q <br /> PENALTY "' y r <br /> fit <br /> OTHER <br /> e <br /> OTHER - <br /> Received by- ate eceipt No. Permit No- Issuance Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.'HAZELTON �.O.Box 2009 STOCKTON;CA 95201 �k <br />