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I Applications Will Be Procesr�d When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicata is hereby made car on bu 'ness i ,:the l'un Ictio al area of the S o ul ocal Health D� trict y <br /> m Business Name (DBA)�i� �i G - b Address N i � /hQ � fL �! <br /> &, a Owneroic ires� e S Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. — Emergency Telephone No. <br /> J Contractor Licence No. . <br /> y� <br /> L Applicants Name (Print) 6 Title �✓�+ io /�� Dale <br /> Please check Applicable Category(1-7) and FIII in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 '( Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> f Capacity Gal., Weights & Measures No. <br /> I Equipment Parking Address <br /> f <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> i 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. ❑ SANITATION PERMIT " ',t '" <br /> Job Address/Locatiol /y3~ �� ��6r/l-r'ti � , /© kf? <br /> Own ­CTAN 1111Address <br /> SEPTINK CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR IN OTHER 0e,r�fcv <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site 4J <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified �w <br /> Plant Location <br /> Plant Capacity No. Units Served �n <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 V t <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ,, ♦'l_ <br /> V Q , U <br /> {. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joa C unty <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. �/�/ <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By nuary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE R TED AMOUNT <br /> ' FEE ` 14 F 'sC F s a-6 <br /> LESS fr <br /> PRORATION <br /> E PLUS <br /> r`[ PENALTY A <br /> I OTHER <br /> { OTHER - <br /> jPiEln <br /> k4 Received by Date Recbipft N6. Permit No. I suance Tate Mailed ADelivered <br /> L` <br /> APPLICANT—RETURN ALL.COPiES TO: JENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKT, .CA 95201 <br />