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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 /> .y ENVIRONMENTAL HEALTH PERMIT <br /> 'r LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of th San Joaquin Local Health District �o , <br /> w Business Name (DBA)��•gel ��-�ZS_"�6 ? Address <br /> z Owner Address <br /> a _ � <br /> 1 Firm Partners, Addresses and Telephone Numbers . + <br /> Business Tel <br /> No. r`�'��' Emergency Telephone No. <br /> a.Contractor Licence No. S — <br />��Applicants Name (Print) LfWll �1 � Title ���td���•— 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 /> F.'.'t <br /> 2.:11 PUMPER YARD f <br /> For July•1, June 30, 19 <br /> 7. No. of Vehicles Stored <br />�r No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST - <br /> R.S. or R.C.E. Name R.S.-6r R.C.E. No. ` <br /> TestLoocc tion Test Date/Time <br /> 4. L SANITATION PERMIT <br /> Job Address/Location p 1 d Z <br /> Ownerddress <br /> ❑ SEPTIC TANK 11 CESSPOOL CEACHING FIELD B SEEPAGE PIT -"0 PACKAGE PLANT <br /> ©PERMANENT ❑ TEMPORARY 11NEW {EPAIR ❑ OTHER t" <br /> 5.' ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site_ g- <br />- Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) - — <br /> 6. 1:1 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 - - + <br />° Where Certified � <br /> Operator Name 4 <br /> Plant Location <br /> Plant Capacity i 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. <br /> 0.DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I h e prepared this applicatio d that t e ork will be done,in accordance with San Joaquin County, <br /> ordinances, state lawS& d ules and r ulations of jie an Joa n Local Health District. <br /> F <br /> APPLICANT'S SIGNATURE <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> F Fee Is Due: 11ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ElJanuary 1 &Received By Janu N 31 ❑ July 1 8 R eived'By July 31 <br /> �.,,.,. ,� REMIT. <br /> BASE EXPLANATION BILLING REMITTANCE $.. r �•� i � AMOUNTDUE CHECKED <br /> DATE .DATE _ REMITTED AMOUNT 4 <br /> FEE •� 4. :i' ` _ - �,,,_, -.. �"" - ,. <br /> LESS • 1� <br /> PRORATION _ 7 xo / <br /> PLUS - i . - <br /> PENALTY } <br /> OTHER <br /> OTHER <br /> 3- 94D 1'7 <br /> r - <br /> Received 6y Date - Receipt No. Permit No. .. suance Dale Mailed eliver <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC ON,CA 5201 <br />