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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 1 APPLICATION # <br /> Lf / 7dZo (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> (� 1lJ J T ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby,made to carry on business in the jurisdictional area of the San Joaquin Local He Ith District <br /> H Business Name L(DBA) 11. W .S;PA1Fj-iied � As4oCIQIeS Address -4045 Copanedo Ave. <br /> a Owner NJ�C4'n wood V 1,40 alar- s Address 1? G. 8pX $97 <br /> J Firm Partners, Addresses and Telephone Numbers s -4111 <br /> aBusiness Telephone No. 943 Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Std t7 Title Date <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 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal 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 /> 3. XPERCOLATION TET S— qQ ! <br /> "RS_or R.C.E. Name )304frt G. cflwn -R�. or R.C.E. No. 1725 I <br /> Test Location IN a 9 ,Fas! F1'd21p r 84ed Test Date/Time <br /> 4. ❑ SANITATION PERMIT <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 <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 /> illim wa.ra.Neaw.wa�awe'a owelbaAwlallo+ll�1:'loertlhllhtMtBe efftworkferMtrichthispermitisissued,fshallnotemployanyperson <br /> in such manner as to hecoof G6fenlla` <br /> s � his l; I Ow f wkw 1 eff"th*in dN pSAormance of the work for which this permit Is issued,I shall <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state lawn rules and reg11latio�e San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE MITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 5 t IWt� �Q p27-/ Q V-�7�• v O�O� Q/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> jf_o� <br /> Received y Date Receipt 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 />