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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.T �. 1 <br /> APPLICATION /Qe,"/z/J <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE 0 - <br /> ENVIRONMENTAL HEALTH PERMIT 7 <br /> LIQUID WASTE <br /> Application I ereby mad to carry o�siness inUkee jurisdictional area of th� J uin Local H aith Istrlct <br /> Business Name (DBA) '_ `r�'"' - Address .7[ + .� <br /> 4 Owner 1,.. Address t <br /> Firm Partners, Addresses and Tel h ne Numbers <br /> aBusiness Telephone No. 64 �j Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> Applicants Name (Print} �}+ Title S Date �� a <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, f Disposal Sites - -_ <br /> Description(Make/Yr., Color) t <br /> Serial No. r 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 +"r <br /> No. of Vehicles Stored <br /> t 1 <br /> No. of Chemical Toilets Stored <br /> ,t <br /> 3. '.❑ PERCOLATION TEST # r <br /> R:S. or R.C.E. Name t R.S.or R:CIEs No. <br /> Test ocation 'Test Date%Time <br /> 4. SANITATION PERMIT r - -- - --- --- <br /> Job Ad'dre /Location <br /> Owner " 1� µ Address <br /> SEPTIC TANKS Q. POOL `-J -1� LEACHING FIELD- W,SEEPAGE':P.IT 0 PACKQ_GE PLANT T <br /> PERMANENT,"P TEMPORARY y s.,, NEW ❑,REPAIR OTHER <br /> 5.' <br /> 0-CHEMICAL TOILETS- For July 1,=�,1une 30, 19 C <br /> Type Construction :Vry LNDisposal_Site r <br /> No. of Units Equipment,Storage/Cleaning Location(s) } <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June-30, 19 <br /> Operator Name i v Where Certified t <br /> Plant Location _ <br /> Plant Capacity. No. Units Served <br /> 7. 11LAUNDRY For July 1, -June 30,-]9 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq: Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Horne owner orfieensWags;nt'Os.g^r nrq,art_?Zosonof-ano�'ving:"!certifjthatinthe performance ofthe work for which this permit isissued,lshall rintempicyanyper°' i <br /> itI stech manner as to become°u�!^.c �o r °_ <br /> Contractor's hiring or ub-com r�r`.iiir. th `ofiowlnoo .i ce ti€y that in I'm performance of the work for which this permit is issued,!shall <br /> -OmplOypersons subi4cttO�~lOTt.fid-.tip.. :,f�.j._�1.,.<.i�C:I�:J�Or�,211iornil . <br /> iO <br /> I hereby certify1hat I have prepared this application and that the work will be done in accordance with San Joaquin County C <br /> ordinances, state laws, an r les and regu ations e Sn Joaquin Local Health District. <br /> :APPLICANT'S SIGNATURE X <br /> n <br /> r _ - 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 /> - - - REMIT <br /> BASF EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 9 <br /> LESS I <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> k M <br /> Received by Date Receipt No, Permit No. Issu ce Da Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E.HAZELTON .O.Box 2009 STOCKTON,CA 95201 <br />