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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revoaable,yand 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 /> M Business Name (DBA) A SW. flG-i�r�s� Address !-,g�-j" _ Jim <br /> z Owner Address <br /> OK <br /> J Firm Partners, Addresses and Telephone Numbers _ <br /> aBusiness Telephone No. — J Emergency Telephone No. <br /> Contractor Licence No. Z3 <br /> ChL <br /> Applicants Name (Print) Title 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 /> '- <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 <br /> R.S. or R.C.E. Name r R.SV or R.0".E.No. <br /> Test Location -Test Date/Time j <br /> 4. IX SANITATION PERMIT Jj <br /> Job Address/Location ` t 64 <br /> OOwrner. J Address a <br /> vV SEPTIC TANK ❑ CESSPOOL � LEACHING FIELD. SEEPAGE PIT 0 PACKAGE PLANT - <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. .❑ CHEMICAL TOILETS For July 1,-June 30, 19 f <br /> Type Construction Disposal Site <br /> No. of Units N Equipment Storage/Cleaning L•ocation(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT-,For July 1, -June 30, 19 <br /> ,Operator Name <br /> ' " Where Certified <br /> Plant Location E <br /> Plant Capacity 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 /> ❑ 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:fid'rules and reg ationJ of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - <br /> • 5 , <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 /> REMIT <br /> �.� }.., BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS 7 <br /> PENALTY <br /> OTHER <br /> OTHER - - <br /> Received by - Date - Receipt No. Permit N ssu ce to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE-P.O.Boa 2009 STOCKTON,CA 95201 <br />