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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application <br /> APPLICATION <br /> l��� <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl ication i hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) L' Address d f�ey7C �� <br /> z OwnerAddress <br /> a <br /> J Firm Partners,"Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. d <br /> L Applicants Name (Print)% Title �/��� ✓��"0 Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> T. ❑ 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 /> 1%,_. ___ -- --� --,:.. ..- .. . „ .� - �w <br /> E s `F _ Y C� <br /> ForJuly,1, J.une.30, 19- <br /> No. of Vehicles Stored <br /> k No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST C <br /> R.S. or R.C.E. Name R.S. or R.C.E.No.y <br /> Test]Location _ lest Date/Time_ <br /> 4. ❑ SANITATION,PERMI. r 4" <br /> Job Address/Location ' 'G <br /> A;ellP <br /> OwVr iAddress <br /> ®/SEPTIC TANk ❑ CESSPOOL ;P-tt-96HING FIELD ❑ SEEPAGE_PIT _❑-PACKAGE PLANT <br /> -.❑ PERMANENT ❑ TEMPORARY ❑ NEW - jOTHER }- f <br /> 'S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site' ` iw <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 -"4 <br /> Plant Location t <br /> Plant Capacity No.Units Served <br /> 7. © LAUNDRY For July 1, -"June 30, 19 w = <br /> SIZE: Less Than 1,000 Sq7 Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - <br /> w <br /> r.. <br /> awl hereby certify that 1 have prepared this application and that the work will be done"in accordance with"San Joaquin.County <br /> Yordinances, state laws, and erUl.:s;and10guI • S of the an Joaquin Local Health District. . <br /> APPLICANT'S SIGNATURE <br /> � Lf. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received Ry July 31 <br /> BILLING REMITTANCE $ <br /> REMIT <br /> BASE` EXPLANATION4t,DATE DATE REMITTED AMOUNT DUE AHECKED <br /> MOUNT <br /> I do, <br /> FEE <br /> t LESS # <br /> PRORATION <br /> PLUS = r <br /> PENALTY <br /> i .. <br /> OTHER' i <br /> OTHER i <br /> 0. <br /> Received by Date Receipt No. - Permil No. Issu nce Datfa Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O:Box 2009 STOCKSON,CA 95201 . <br />