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Applications-Will Be'Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicat'on is hereby made.to Carl.-Lon u +Hess in the jurisdictional area of th an Jdaquiri orpl Health Distri <br /> F <br /> Address <br /> Business m Business Name (DBA) , <br /> z Owner L Address <br /> a <br /> J Firm Partners,Addresses and T p e Numbers S f <br /> CL Business Telephone No. Emergency Telephone No. cO <br /> aContractor Licence No. <br /> f Applicants,Name.(Print),.. L__ Title r C- Date ��ll <br /> Please-check Applicable Category (1-7) and Fill in the Required Information �J <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,. June 30, 19 Disposal Sites <br /> Description(Make/Yr., Col_or) <br /> Serial No. _ CAL. License No. 'r s" GAL. License Renewal No. f�1 <br /> Capacity, Gal."Weights'&Measures-No <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD r <br /> For July 1," June 30-,_1 9 <br /> No. of Vehicles Stored" <br /> No. of Chemical Toilets Stored ` <br /> .Y+ <br /> 3. ❑ PERCOLATION TEST '".` m.s Y " <br /> R.S. or A.C.E. Name R.S. or R.C.E:No. <br /> Test Location Test Date/TimeIr <br /> 4._❑ SANITATION PE IT <br /> Job Add ess/Location . <br /> L. c s y1 <br /> -Owner t Address <br /> �. ,- <br /> X44 _ <br /> []'SEPTIC TANK ❑ CESSPOOL EACHING FIELD ❑ SEEPAGE PIT }'❑ PACKAGE PLANT, <br /> PERMANENT ❑ TEMPORARY NEW .'` a •' <br /> REPAIR r OTHER <br /> 4 5.3 ❑ 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 July7-'June 30, 19 <br /> - Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> {` 7.` ❑ LAUNDRY For July 1, -June 30, 19 -w <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than•1,000 Sq. Ft. <br /> E]'DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certif hat I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> F ordinances, st to la and rule;��d eulation of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> Fee IS Due: ❑ ANNUALLY PER UNIT ❑-PER SITE 11 EACH ❑ January 1 8 Received By January 31 El July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> I� AMOUNT <br /> FEE <br /> LESS <br /> �. PRORATION , <br /> PLUS <br /> PENALTY ' <br /> OTHER ' <br /> ~ OTHER <br /> F ' <br /> Received by IDalle Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601'E.HAZELTON AVE.,P.O o:2009 T C T GA 95201 <br />