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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 /> rn Business Name (DBA) PA I'la9ji SONS rtiC. Address H01-5 « v $Tk Gam• Szo/ <br /> i Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. G- 96o Emergency Telephone No. <br /> Contractor Licence No. 44 <br /> L Applicants Name (Print) sr�NLEr/ M Title E Date <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 <br /> 3. ❑ PERCOLATION TEST I <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Lo ation Test Date/Time <br /> 4. t*� SANITATION PERMIT .0 <br /> Job Address/Location X410 <br /> � T GRA <br /> Owner - � Address � <br /> ASEPT <br /> CESSPOOL ILEACHING FIELD El SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW 5 REPAIR 0 OTHER Q <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 #11 <br /> Type Construction Disposal Site t <br /> No. of Units Equipment Storage/Cleaning Locations) 1 <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 /> I 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, a rules and r ulations f�SJJ'paquin Local Health District. <br /> 1 <br /> APPLICANT'S SIGNATURE X f <br /> s �zgo <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> Fee Is Due: © ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED - <br /> DATE DATE REMITTED AMOUNT <br /> i FEE 4 0 <br /> LESS <br /> PRORATION _ <br /> l PLUS <br /> I PENALTY qp EJ1 <br /> OTHER' W 1 A <br /> OTHER <br />�I`I4 Received by Date Receipt No, Permit No, Iss ane Date Mailed Delivered <br /> I - APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCXTON,CA 95201 <br />