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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> 0 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application Is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) aN sl-OISR- Address 2&2'5 A;, mY/277_9 57- —STd G*7Dn1 <br /> a Owner 071U4fN3L 7-1 !34.4-7-7- Address yAAS A/1 PI£ftS1t-Jtir6 '+UlF — SJVrx d>v <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 269- 94a-I'3rf.S Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) -'5575u&--J R, 019VI S Title 6� -�ygT Date 4/ t,'-9'7 <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 <br /> Description(Make/Yr., Color) <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 N <br /> 3. )d PERCOLATION TEST k 7-Zen p� <br /> R.S. or R.C.E. Name Op" /1r1N',,r - R.S. <br /> g.S.or R.C.E.No. z <br /> Test Location h/�nf,'W 442J& 'TD1h�A7716)u e/Time `'67-Z4P q-Z7-68 <br /> 4. ❑ SANITATION PERMIT 4o75 Z'/ A, y! `Sl 6 9i� _26y pAgQLs <br /> Job Address/Location r\` <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT r <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <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 t� <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. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> e� <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, and ulea and regulations of the San Joaquin Local Health District, <br /> - APPLICANT'S SIGNATURE X ry <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 05 r 01 DATE DATE REMITTED AMOUNT <br /> FEE 3Cr5j <br /> LESS <br /> PRORATION L <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> **+ <br /> Received'by Dae Receipt No. Permit No. Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />