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t Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> APPLICATION <br /> —0. (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> _ __ Y ENVIRONMENTAL HEALTH PERMIT t 3.--0 FO <br /> ;r. „� ,d LIQUID WASTE <br /> Application i;hereby g4ade to carry on business in the jurisdictional area of the San Joaquin Local Health District . <br /> ,,Business Name (DBA) �QSr(� /l.tl;5-r 41G'T! IA/ Address ! YLIAPLt v <br /> i Owner i Address - <br /> a F <br /> Firm Partners, Addresses and Telephone Numbers <br /> X39 7� Emergency Telephone No. <br /> CL Business Telephone No.— <br /> a <br /> Contractor Licence No. � �QQ <br /> L Applicants Name (Print)_�L4 4 D -1�/ Title ' Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information f" Fig -- <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 /> 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 /> 4 Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT X. 16 k1A <br /> Job Address/Location _ <br /> � ,1/. /�DQDS Address <br /> Ow ner R7SEPTIC TANK 11 CESSPOOL I O,�W,r LEACHING FIELD SEEPA ❑GE PIT 13 PACKAGE PLANT y j <br /> u>LNEW ❑ REPAIR OTHER Q <br /> f PERMANENT ❑ TEMPORARYr F,� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19. <br /> Type Constructionr c Disposal Site <br /> No. of U <br /> nits. _ 5 Equip exit Storage/Cleaning Location(s) <br /> a; - <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,r June 30, 19 a <br /> Operator Name k' Where Certified Plant Location. <br /> Location, <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 14000 5q. Ft. Z <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. w <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 an Joatluin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Dile: ❑ ANNUALLY ❑ PER UNIT ax❑ PER SITE ❑ EACH ❑ January 1,&Received By January 31 El July 1 &Received By 31 <br /> BILLING REMITTANCE $ AMOUNT-DUE CHECKED <br /> ` BASE EXPLANATION DATE - DATE REMITTED AMOUNT <br /> FEE A <br /> a <br /> c LESS .,.�- <br /> "` PRORATION <br /> PLUS It, a <br /> 's <br /> PENALTY <br /> • / y 1 � y <br /> OTHER <br /> OTHER <br /> Received by Date "Receipt No Permit No. I uance D e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON•CA 95201'` <br />