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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> C� C} 6 . APPLICATION <br /> f i z-9f0 (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> "( ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application ereby made to carry on business in the jurisdictional area of the San Joaquin Local Oath District <br /> H Business Name (DBA) -s�/.�YJ(` /- $r�-� Address !0602%e /��C <br /> a Owner /� e C z9a4,,y-A,-, Address ;91,&2 b �/ <br /> J Firm Partners, Addresses and Telephone Numbers <br /> M Business Telephone No. Emergency Telephone No. -4�/�+ t A <br /> Contractor Licence No. 46 <br /> Applicants Name (Print) /��,L�.CC h t A!O'7o V Title R C Date g�tZ <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 —_ 9 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccnse 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 O <br /> 4,,ffSANITATION PERMIT ` <br /> Job Address/Location t� A V <br /> Owner,/?7A #107' dF1 4. Y o Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING 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 0�1 <br /> No. of Units Equipment Storage/Cleaning Location(s) g3 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> ' ant 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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - rl <br /> n <br /> 1 <br /> 1 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, and rules and re reg l a Sanoaquin Local Health District. //// � ���"��APPLICANT'S SIGNATURE X ,/-'-L� ! <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE F7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ` <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I su n e Date Mailed Delivered <br /> 1. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON.AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />