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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applicat_ ion. „ � <br /> / <br /> APPLICATION <br /> f"r (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> F LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District 5 <br /> Business Name (DBA) � ��/��i�S'/�14 Address. G. S <br /> aOwner ;._ - �� ..Address <br /> J Firm Partners, Addresses and Telephone Numbers {. <br /> a :Emergency Telephone No. <br /> Q. Business-Telephone No. - .. �, , <br /> Contractor Licence No. f pQ <br /> LApplicants Name (Print) Title IfGE�TDate <br /> . <br /> Please check Applicable Category (1-7) and Fill in the Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) �} r <br /> For'July 1, -- '--June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) ..- <br /> _ cense No. CAL. License Renewal No. <br /> Serial No. CAL. Li <br /> Capacity .. Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD r' <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored x <br /> 3. 0 PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. Uy <br /> Test <br /> Test Location' i I]ate/Time <br /> 4.X SANITATION PERMIT _ <br /> Job Address/Location Sao <br /> Owner Address �xw x t/ <br /> ❑ SEPTIC TANK ❑ CESSPOOL`""""" ❑'LEACHING FIELD ❑ SEEPAGE PIT 0 PACKAGE PLANT <br /> 11 PERMANENT 0 TEMPORARY - 13 NEW 11 REPAIR .OTHER ��kP� <br /> 5. 0 CHEMICAL TOILETS For July 1, -June 30, 19 ; <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. 0 PACKAGE TREATMENT PLANT For July 1,-June�30, 19 <br /> Operator Name <br /> # } Where Certified <br /> Plant Location <br /> Plant Capacity } No. Units Served * i <br /> 7. 0 LAUNDRY For July 1; -June 30, 19 F <br /> SIZE: 0 Less Than 1,000 Sq*Ft., 0 More Than 1,000 Sq. Ft. ' <br /> ed!Amount/Mo <br /> sS.x1+{nfrrr� .rr n r of rur;,:"1ce:ti==tti, tf:eperformanceoftheviorkforwhichthispermitisis;ued,Ishallnotemptoyanyperson <br /> : (1 317 r131$; S44i=1S4C$"Ned <br /> onxcgc4vr's 5frirm frr tee.s� ract�. �a, c. :: �,,;t;siE� ;; toiiowing: "I certify that in the performance of Ille woods for tidiic;,this permit i5 issued.I shall <br /> . i+ 1d�YSP�,cGU{7etsicflrcrnarisconsp�r aac::!av+sc!Gai;!crnia.' y . <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 regulations of San Joaquin Local Health District. V <br /> t <br /> APPLICANT'S SIGNATURE X <br /> Ftk FOR DEPARTMENT US ONLY <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT. PER SITE � ❑ EACH '❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> l BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ,r DATE DATE REMITTED AMOUNT _ <br /> z/D <br /> FEE r <br /> LESS <br /> 'PRORATION <br /> PLUS <br /> PENALTY }• <br /> .. OTHER <br /> OTHER <br /> 1&0 -7 L36 <br /> Received by Date Receipt No. Permit No. Issuan a Date Mailed. Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2409 STOCKTON,GA 95201 <br />