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APPLICATION <br /> (For Non-Transferable, Revocable, and Suspenda—w) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT --rc-p\E:51 <br /> LIQUID WASTE <br /> Application is hereby made to rry on business in the jurisdictional area of th San oaquin Local Health District <br /> Business Name (DBA) %w1d ,IZ,A Address_ 2 W. Elr 952A <br /> Owner `FERRY PIr,Z7A _ Address 02'� W_ F/ _tvd SM L gW G�-•-__� <br /> Firm Partners, Addresses and Telephone __3���Jt//0-�10_ <br /> 0. Business Telephone No. ����� y __._. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) -MPLRY[ PJ4Z A __ _ Title --at P--, Date Z <br /> Please check Applicable Category (1-7) and Fig 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. AL License No. CAL. License Renewal No. <br /> Capacity Gal., Weig s & Measures No <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, _ June 30, 19 <br /> No. of Vehicles Stored <br /> No Doff Chemical Toilets Stored <br /> 3. m PERCOLATION TEST <br /> R.S. or .C.E Name TERRY P1�27�4 _ _-- R.S. or(mNo 19& <br /> Test Location 217010 e 2Test Date/Time - <br /> 4. ❑ SANITATION PERMIT RY L�GAhl1 Pt7r��• <br /> Job Address/Location -- <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <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 Where Certified <br /> Plant Location f <br /> Plant Capacity _ No. Units Served VVVV <br /> 7. ❑ LAUNDRY For July 1. -June 30, 19 <br /> SIZE ❑ Less Than 1,000 Sq Ft , ❑ More Than 1,000 Sq. Ft. ��+ �X' 1 Z/ <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ——__---- / 1 <br /> I hereby certify that I have re this applic n an that the work will be done in accordance with San Joaquin County <br /> ordinances, state law n r e and regulatio of an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - - <br /> 4 `rl`5T t-iJ4E5 oP.G�L� (, 2, ?' RE►,�1 LSI u1Z. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1&Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> � <br /> y DATE DATE REMITTED AAM'OODUNT__ <br /> tfFEE IC( /,-- e0� —fes _-1� L CSO - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY —_ <br /> OTHER <br /> OTHER <br /> - <br /> Recerved y Date Rece_�ppt No Permit No - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTON,CA 95201 <br />