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JAPP11GG11VI{O ".11 oC r.VICD3UW 7YIIC11AUU11119MU r'Ivperly 4U111FiUteU. Old OUre IQ QIWn IneAppuumion. <br /> •�ti. APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> t LIQUID WASTE . <br /> Application is h reb made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ` !Business Name (DBA) Address <br /> fr- � "• P ��- � Address 1��_.--..-- <br /> Owner. <br /> Firm Partners, Addresses and Tele hono Numbors '-.�_ i � <br /> Business Telephone No. — I r �wd Emergency Telephone No. <br /> Contractor Licence No. <br /> .Applicants Name (Print) .- ...,- ` _ Title , <br /> Date <br /> { Please check Applicable Category (1-7) and Fllf In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> { For July 1, _June 30, 19 -- Disposal Sites <br /> ' F Description(Make/Yr., Color)--- <br /> Serial <br /> -Serial No, i CAL. License No. - CAL. License Renewal No. <br /> I Capacity — — Gal.,Weights 8 Measures No. — —_ <br /> { <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> • For July 1, June 30, i9No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> + 3. ❑ PERCOLATION TEST 1 - <br /> R.S. or R.G.E. Name ---- ..._.•.__ R.S. or R.C.E. No. <br /> Test Location l Test Date/Time <br /> " 4. ❑ SANITATION PERMIT a' <br /> Job Address/Location d•' <br /> OwnerAddress :2'r32 SP _. " <br /> 01�EPTIC TANK a ❑ CESSPOOL' Q<EACHING FIELD ❑ SEEPAGE PIT © PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction ( Disposal Site <br /> No. of Units , i Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name — _ _� Where Certlfled <br /> Plant Location `( _ <br /> Plant Capacity No. Units Served _ <br /> 7. C1LAUNDRY For July 1, -June 30, 19 — <br /> SIZE: ❑ Less Than 1,000 Sq, Ft., 1 ❑ More Than 1,000 Sq. Ft. / Q <br /> i ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> r- <br /> a � I� <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Jo in County c- <br /> ordinances, state laws, and rules and regulati ns of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 d Received By Ju 31 <br /> BILLING REMITTANCE $ 71 REMIT <br /> RASE EXPLANATION DATE DATE REMITTED AMOUNT t)UE CHECKIi:t] <br /> _ AMOUNT <br /> FEE <br /> I LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> � OTHER ---- — ----- - <br /> OTHER — <br /> Received by Date ._ Roceipi No, Pefrnil No. Issuance Dole Mailed Delivered <br /> I APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95 <br />