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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 /> 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 /> O Business Name (DBA) G & L Engineering Address 551 No. Hunter St. , Ste 1, Stockton <br /> aOwner Dean G. Gilman Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No.(209) 941- 8777 Emergency Telephone No.(9r1- 9)4637807 <br /> Contractor Licence No. <br /> Applicants Name (Print) Dean G_ Gilman Title twiner Date 3-R-R$ <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 Lo i- <br /> 3. XQ PERCOLATION TEST MS 88-31 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. RrE 33033 ` <br /> Test Location Copperopolis and D iST-est Date/Time - <br /> 4. ❑ SANITATION PERMIT 3r/4 C (TD /9/1- / <br /> Job Address/Location <br /> Owner 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 <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 N <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 G <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. A�1 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. V <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 r)dVsand regulation f th an aquin 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 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 <br /> �.� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> sly,Ik <br /> Re ved by DAte Receipt No. Permit No. Issuance Date Mailed Delivered <br /> PLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> s <br />