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Applications Will Be Processed When Submittal Properly Complete a ure <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and 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 Joan Local Health Di�r ctt + <br /> _ Address <br /> r Business Name(DSA) - <br /> a Owner s-�Ca�L Address J ' <br /> 2 Firm Partners,Addresses and Telephone Numbers Emergency Telephone No. <br /> 4-Business Telephone No. h _ J + <br /> Contractor Licence N0. L+�J _ Title Date <br /> Applicants Name(Print) - +�vGGr:�r J <br /> t 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(MakelYr.,Color)— <br /> CAL. License No. GAL, License Renewal No., <br /> Serial Nn. <br /> I Capacity. •-.,- ----�-~Gal;Weights&Measures--NO. <br /> •"' J �. •� r <br /> Equipment Parking Address� -�� ��_Y-•- -.-... ..._� .._., _.. �.. .. <br /> 2. ❑ PUMPER YARD <br /> t Far July 1, dune 30,19 -- — <br /> r , <br /> No,of Vehicles Stored J <br /> No-of Chemical Toilets Stored <br /> :g <br /> 3. ❑ PERCOLATION TEST +`` 4�' + <br /> k9:or R.C.E.No. W <br /> I R.S.or R.G.E.Name <br /> Test Date/Time <br /> Test Location <br /> I 4. ❑ SANITATION PERMIT <br /> Job Address/Location- <br /> Address p <br /> c Own ❑ PACKAGE PLANT <br /> F tYI EPTIC TANK ❑ CESSPOOL EACFiING FIELL} ❑ SEEPAGE PIT ❑ OTHER <br /> ❑ PERMANENT ❑ TEMPORAflY ❑ NEW ;, ❑ REPAIR <br /> [ F- Y <br /> §. ❑ CHEMICAL TOILETS For duly 1,-June 30, 19, <br /> Type Construction_ f Disposal Site _ y <br /> No.of Units Equipment Stora''ge/Cleaniisg�Location(s) J� <br /> ( , <br /> g_ ❑ PACKAGE TREATMENT PLANT For July 1,-June 30�i9'��__ where Certified -- <br /> Operator Name - <br /> ' Plant Location r <br /> Served - <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1,-Jung 30, i9 { + <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.', ❑ More Than 1.0� 9• F rx <br /> [ ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> i <br /> E I hereby certify that 1 hAve prepared this application and that the work will be dune in accordance with San Joaquin County <br /> ordinances, state laws,and rules and reg la' s of the San Joaquin Local Health District. <br /> e <br /> APPLICANT'S SIGNATURE X <br /> ) <br /> r - <br /> I # FOR DEPARTMENT USE ONLY L <br /> i <br /> Fee IS Due: ❑ ANNUALLY Q PER UNIT ❑ PER SITE ❑ EA ❑ Janu ry 1 B fleceived By January 31 ❑July i h Received By July 31 <br /> W oiLLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED _— _ AMOUNT <br /> I FEELESS <br /> Y <br /> PRORATION <br /> r PLUS I� <br /> i PENALTY <br /> OTHER <br /> OTHER <br /> HBCnived by f nate f HeCe:pt No <br /> Permit No. Issuance Date Mailed Delivered 1601 E.HAZELTON AVE-,P.O.BOX 20D9 STOCtSTON,CA 4;1;r <br /> -- APPLICANT�RETURN ALL COPIES TO: ENVIRbNMENTAL HEALTH PERMITISERVICES F <br />