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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />/IV APPLICATION <br />V(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 Joaquin Local Health District <br />N Business Name (DBA) C� �z r 17 Address 4nob So Cem •T I�t-4�' Si'nc/�i�� <br />a Owner A /moi /t 0 AJ Y l /(J Address <br />Firm Partners, Addresses and Telephone Numbers 44A �'f , 1 2dJ"- <br />a Business Telephone No. (� co �� <br />`+ _ � � `? � Emergency Telephone No. <br />Contractor Licence No. <br />T <br />Applicants Name (Print) % Lke- r ?hyo Title C r- L- Date �r� --16 <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 Q <br />Description (Make/Yr., Color) <br />Serial No. <br />Capacity <br />Equipment Parking Address <br />2. ❑ PUMPER YARD <br />For July 1, June 30, 19 <br />No. of Vehicles Stored <br />CAL. License No. <br />Gal., Weights & Measures No. <br />CAL. License Renewal No. <br />No. of Chemical Toilets Stored <br />❑ PERCOLATION TEST <br />R.S. or R.C.E. Name hyZ 112 0,_ OAJ -7aFW— W— R.S. or R.C.E. No. �' _ 4 Zito <br />Test Location &'eF'V I? /�j`-- ��" y���� Test Date/Time j <br />4. ❑ SANITATION PERMIT <br />Job Address/Location <br />Owner Address <br />❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT r <br />❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br />5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 �\ <br />Type Construction Disposal Site <br />No. of Units Equipment Storage/Cleaning Location(s) <br />6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 <br />Operator Name <br />Plant Location <br />Plant Capacity <br />7. ❑ LAUNDRY <br />For July 1, - June 30, 19 <br />SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br />❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br />No. Units Served <br />I hereby certify that I <br />ordinances, state laws <br />Y APPLICANT'S SIGNATURE <br />Where Certified <br />pplicati+on and th the work will be done in accordance with San Joaquin County <br />rules and reculationsA the%an nanrlind In eri nlor. r <br />FOR DEPARTMENT USE ONLY <br />Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ .lanllary 1 R Rorcw.H R.. ion �... 01 I l <br />-^ • Issuance uace Mailed Delivered <br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON, CA 95201 <br />..,...,,,..� <br />...y u <br />--vu oy July 31 <br />BASE <br />EXPLANATION BILLING REMITTANCE <br />$ <br />REMIT <br />DATE DATE <br />REMITTED <br />AMOUNT DUE <br />CHECKED <br />FEE <br />AMOUNT <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />'Y1 <br />3� <br />Received by <br />Date Ra f N o <br />-^ • Issuance uace Mailed Delivered <br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON, CA 95201 <br />