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Applications Will Be Processed When Submitted Properly Completed. Be Sure To.Sign The Application. <br /> Q APPLICATION <br /> (For Non-Transferable;Revocable,-and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTHR-ERMIT <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) MTp7A 14 Septi n EgRg.�kl4ge ` Address �– <br /> zOwner T - -: � :M.r_Do Ig 2 1 cl , Address. Sin-A <br /> a - <br /> Firm Partners, Addresses and Telephone Numbers - <br /> CL <br /> Business.Telephone No. -.91-0 49 7 Emergency Telephone No. 9 57-�4 7 E– <br /> �Contractor Licence No. 1 3 3A'7QdK <br /> s 'I <br /> Applicants Name (Print)— =—j Q �'° Title Own-e32 Date <br /> Please check Applicable Category (1-7) and Fill In the Required Information .,. k r ;• y Y ?, r(,' <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 a T <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 <br /> 4. ❑ SANITATION PERMITS va,Job Address/Loc tion 1 <br /> Owner r Address <br /> C SEPT TANK ❑ CES OL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY kNEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site 1 <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 \ <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 /> 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 rules and regulatio of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <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 /> f AMOUNT <br /> � <br /> " FEEcJ <br /> LESS <br /> PRORATION 3 <br /> PLUS <br /> PENALTY <br /> OTHER 1 <br /> 1 <br /> .OTHER <br /> Received by I-, �to Receipt No. Permit No. ssuan Dae Mailed Delivered --- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16011 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />