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Applications Will Be Processed When Submitted Properly Completed. BeSure 10 btgn Enewppncntla16. <br /> APPLICATION <br /> V (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQU16 WASTE <br /> Application is hereby made to carry on bus' ss in the j risdictional area of the San Joaquin Lo, al Health District <br /> rn Business Name(DBA) L Address <br /> I ALT . <br /> I ��_ Address <br /> a Owner 1� <br /> J Firm Partners, Addresses and I ne Numbers <br /> a. Emergency Telephone No. <br /> a Business Telephone No. , <br /> Ci <br /> Contractor Licence Na. <br /> P: % j is ka Title to <br /> LtApplicants Narne_(Print)��.'". , �-- - •- <br /> r: r <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, lJune'30, 1- .f -``=-"Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL.`t_icense Renewal No. <br /> s t ')JI <br /> ,Capacity'"" "'-"- "� GaLTWeights-&Measures No. <br /> Equipment Parking Address <br /> ' 2. ❑ PUMPER YARD 'r <br /> For July 1, June 30, 19 " <br /> No.pf Vehicles Stored <br /> No. of Chemical Toilets Stored ( in <br /> 3. ❑ PERCOLATION TEST n <br /> R.S.�or R.C.E. Name R a _ R.S. or R.C.E. No. <br /> _ s•� i <br /> iTest Date/Time 1 <br /> Test�Location G <br /> 4. ❑ SANITATION PET(� } p ] t <br /> Job!Addres /Location [ ; <br /> Owner Address f <br /> El SEPTIC TANK ❑ CESSPOOL LEACHING FIELD - SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11PERMANENT ❑ TEMPORARY ❑ NEW r� •{ ° REPAIR i ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19r <br /> Type Construction Disposal Site <br /> t <br /> ND.of Units Equipment Storage/Cleaning Location(s) UUUIII <br /> 6. ❑ PACKAGE TREATMENT:PLANT For July 1, -June 30, 19 a • 1 <br /> } "; ` <br /> = Where Certified. <br /> Operator Name ! � <br /> Plant Location <br /> h ' b. Units Served <br /> Plant Capacity e ! <br /> ❑ LAUNDRY For July 1,-June 30, 19 , <br /> S1ZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1 000 Sq Ftk' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo "SSR # 1sr 1 <br /> -W P. this afip kation and thhe work will be done-in-accordance-with-San Joaqllin County i ;I hereby certify vprepordinances, stat laws, a d r g aand re ulation ?tSjn o uin L 1'H h:District. <br /> Y }•. <br /> APP'LICANT'S SIGNATURE X <br /> i <br /> j - FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT' ❑ PER SITE ❑ EACH El Januarys &Received,By January 31 ❑ July 1 &Received By July 3t, ' <br /> ' - REMIT �. <br /> BASE EXPLANATION BILLING !I REMITTANCE AMOUNT DUE CHECKED -S <br /> DATE ?- DATE REMITTED AMOUNT , <br /> FEE <br /> 5•e ,� <br /> LESS <br /> PRORATION M' <br /> f <br /> PLUS - <br /> PENALTY <br /> 331 <br /> OTHER '� t <br /> OTHER t <br /> Recei by� — to Receipt No.. +J ,' Permit No.' sW t Issuance Date Mailed <br /> i <br /> APPLICANT—RETURN ALL cOPIES TO: ENVIRONMENTAL'HEALTH PERMITlSERVICES 1601 E.HAZELTON AVE.,P.O.Box 20179 STOCKTDN,CA 95201 <br />