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{ Applications Will Be Proce ss ed Whiri Properly Completed. Be SureTo SignTheApplication. <br /> A LICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> w <br /> LIQUID WASTE <br /> u Application is hereby made to carry on burin sin the juris ictional area of the San Joaquin local H alth District <br /> Business Name (DBA) <br /> z Owner ���� Address <br /> a rAp 49 <br /> D' Firm Partners, Addresses and Telephone Numbers <br /> CL Telephone No. Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> L Applicants Name (Print)itT3�2DNN Title CGS Dat 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) <br /> Serial No. CAL. License No. GAL. 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.S. or R.C.E. No. <br /> Test ocation Test Date/Time <br /> 4 SANITATION PERMIT / ��• �l <br /> Job Address/Location 1" Aft hr � -EW , / 23 �, Vii <br /> Owner "•,e Address Z74e, V. <br /> ❑ SEPTIC TANK ❑ CESSPOOL lid LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT f <br /> 11 PERMANENT /TEMPORARY NEW /REPAIR ❑ OTHER n��` �•�C{-fir / _ J <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site !L �� .1 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 .L <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> r 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, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SI TURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: C1ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 13 Januar 1 Rved By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REM $ AMOUNT DUE CHECKED <br /> DATE A REMMIITTED AMOUNT <br /> FEE �S D r� <br /> LESS /� <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> t <br /> OTHER <br /> -7 /) 7 ,1 <br /> Received by I Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />