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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ^ <br /> k APPLICATION ' <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> - 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 /> Business Name (DBA) 1. Address T14 SSZC>1 <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No.�G—91007 Emergency Telephone No. <br /> Contractor Licence No. Z <br /> L Applicants Name (Print) ZTAN LEY 19- -9I Title Date S— j <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) I <br /> Serial No. CAL: License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address -' <br /> 2. ❑ PUMPER YARD 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. DISANITATION PERMIT <br /> Job Address Location-[Z-98A Ltd. MACCN0tJA(_M _ <br /> Ownn r ._ �9�14-y -G ZA" ,� Address �L i LA 1J <br /> L�SEPTIC TANK iJ CESSPOOL M--CEACHiNG FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY M--KEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <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 4T 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. Q <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that ve prepared thi application a that thew k will be done in accordance with San Joaquin County <br /> ordinances, state la es and r ulations of an JoaI He Ith 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 /> ' <br /> BILLING -REMITTANCE $ REMIT <br /> BASE a EXPLANATION DATE' DATE REMITTED AMOUNT DUE CHECKED <br /> _ AMOUNT <br /> FEE <br /> S �gt <br /> LESS <br /> PRORATION C S r t <br /> PLUS <br /> PENALTY p l_./L • "'+- <br /> L Q[Jt} <br /> OTHER <br /> OTHER -�v�✓! 1 a <br /> Received by Date Receipt No, Permit No. Issuahce Dpte Malted Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BOX 2009 STOCKTON,CA 95201 <br />