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•... .�..� <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSign e1 <br /> APPLICATION _ > ¢- ..` <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE 'l-4 <br /> -- ENVIRONMENTAL HEALTH PERMIT . t 1 -s .�V+ , <br /> LIQUID WASTE "} - ±.S I " "1 � <br /> Application is hereby made W carry 0 business in the jurisdictional area of the San Joaquin Local Health District CA. <br /> , w <br /> f -+4.1� G151 Address .p O, <br /> w Business Name (DBA) <br /> Address <br /> z Owner <br /> Firm Partners, Addresses and Telephone Numbers - <br /> a Business Telephone No. �4L� Emergency Telephone No. a - <br /> a <br /> Contractor Licence No. '— <br /> d - Title. STI Yi%t i4-t-� le = Date..._f <br /> L Applicants Name (Print) <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, 1une'30, 19 <br /> ^- Disposal Sites. _- - --... .,•, . .._._.__._,...- _._—_ ,. ..- <br /> Description,(M-pke/Yr.,.Golor) se <br /> •` <br /> Serial No. <br /> CAL. LicenNo. CAL.License Renewal N ... <br /> Capacity Gai.�Weights & Measures No. i <br /> Equipment Parking Address -• <br /> 2. ❑ PUMPER YARD i <br /> For July 1, ,une 30, 19 — <br /> No. <br /> 9 No.of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST t. - <br /> R.S. or R.C.E. Name <br /> R.S. or R.C.E. No. <br /> Test�,Loca n 7 t x�' it Test Date/Time <br /> 4. ISSANITATION PERMIT'' i"r " ^� A�r;�f' 4- <br /> Job Address/Location 1 �' 00 <br /> �.. - ..,.-.a•�._.Address <br /> Owner ❑ LEACHING FIELD ❑ SEEPAGE PIT °- 0 PACKAGE PLANT I <br /> ❑ SEPTIC TANK ❑,CESSPOOL <br /> �ERMANENT ❑.TEMPORARY � NE_W. 0 REPAIR (ITOTHER .�W X 10 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30 19 <br /> Type Construction <br /> - I Disposal Site 4 <br /> No. of Units �� Equipment Storage/Cleaning Location(s) tt <br /> 6. ❑`PACKAGE TREATMENT;PLANT For July 1, -June 30, 19 F Where Certified I <br /> H"" . . .. <br /> Operator Name ) ) <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June-30, 19 ; ! AP: <br /> Than 1,000 Sq. Ft. <br /> SIZE: ❑ Less Than 1,000 5q. Ft., ❑ More _ <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I hav epared'this application and th the_work will-be done in accordance with San Joaquin County <br /> s ordinances, state laws, rid ations of _ S J aqui -oval 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 &Receiv REMITuIy 31 <br /> a <br /> f BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> IN . <br /> FEE- - q6 <br /> p, LESS <br /> ' PRORATtON+' --� ; <br /> PLUS <br /> F' PENALTY - <br /> � ! .1 <br /> 3 3 <br /> OTHER- - 3 <br /> i OTHER <br /> Received by <br /> Dale Receipt No- Permit No. Is ce D to Mailed Delivered <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2909 STOCKTON.CA 95201 <br />