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Applications Will Be ProcessedWhen Submitted Properly competeo. Ise cure o ply ^PPS��•"• <br /> APPLICATION <br /> t Non-Transferable, Revocable, and Suspendablty SEPTAGE <br /> ` ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is 2by made to rryon bush ss in the jurisd'�7tttonal area of the Sa/n�Joaquin Local Health District11 <br /> q"19usinea Name (D ) r <br /> ' r o`C/G Address y 0 �7�'t' 76 _7 � �" <br /> aOwner m4sti+• .-�� Addre-- <br /> '. =irm Partners, Addresses and Telephone Numbers - <br /> Ih,lusiness Telephone No. r/0 6 _ _ Emergency Telephone No. 0 <br /> 11 Contractor Licence No. -' <br /> aTitle Date <br /> 4pplicants Name (Print) — <br /> — <br /> LPlease check Applicable Category (1-7) and Fill in the Required In ormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) (� <br /> For July 1, June 30, 19 Disposal Sites <br /> Le <br /> CAL.License Renewal No. <br /> scription(Make/Yr.,Color) -- -— - <br /> �6erial No. CAL. License 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 /> . ❑ PERCOLATION TEST <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. <br /> Test�Lo tion Test Date/Time <br /> �„4. SANITATION PERMIT n <br /> Job Address/Location ® /6 <br /> Ow �rY , �� Address <br /> Lry3 yC,�EPTIC TANK ❑ CESS POOL LEACHING FIELD ❑ SEEPAGE PIT 11 PACKAGE PLANT O <br /> `IP PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 O <br /> Type Construction Disposal Site <br /> I 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 - <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 1,000 Sq. Ft. <br /> ""❑ DRY CLEANING, Chemicals Used/Amount/Mo. - - <br /> ` I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin unty, <br /> ordinances, state laws, and rulesand gulations of the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 97 <br /> We, FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11ANNUALLY ❑ PER UNIT ❑ PER SITE 11EACH ❑ January 1 A Received y ary 3 Juty 1 d eiv w By JT 1y 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ MOUNT DUE CHECKED <br /> GATE DATE REMITTE AMOUNT <br /> FEE <br /> L LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> L OTHER <br /> OTHER <br /> V IJV I � 1 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed livered .... <br /> V. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES )601 E.HAZELTON AVE.,P.O.Boa 2000 STOCKTON,CA 95201 <br />