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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 /> uQulo wasrE <br /> Application is by made to rry on bust ss in the jurisd' tonal area of the San Joaquin Local Health District <br /> y Business Name (DB ) j cMe- Address 45--k- -7 G 1W-n <br /> i OwnerAddress " <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. -s68 Jr O S Emergency Telephone No. <br /> Contractor Licence No. d <br /> LApplicants Name (Print) Title Date <br /> Please heck'Appfica&_ Category (1-7)and Fill In the Required In ormation <br /> 1. ❑,PUMPER.VEHICLE' PERMIT REGISTRATION (FOR EACH VEHICLE) b1 <br /> For July 1, June 30, 19 Disposal Sites r <br /> -Description(Make/Yr., Color) --- a - -1. i� <br /> Serial No. _ CAL. License No. CAL. License Renewal No. <br /> e Capacity r rte` Gal., Weights &Measures No. I <br />! Equipment Parking Address y >L.:_ ._ all <br /> 2. ❑ PUMPER YARD a + <br /> For July 1, ' June 30, 19 <br /> No. of Vehicles Stored e i <br /> r A, ' A <br /> No. of Chemical Toilets Stored <br /> 3. ❑ 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. L"� SANITATION PERMIT <br /> Job Add re /Location �• � ®-. - "Aj �: _ �. . a <br /> Ow Address �R - <br /> L► 1TIC TANK ❑ CESSPOOL LEACHING FIELD [& <br /> SWAGE PIT ❑ PACKAGE PLANT r <br /> ;"PERMANENT ❑ TEMPORARY 0 NEW 'REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 k <br /> d ' <br /> Type Construction Disposal Site t1 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19R f <br /> Operator Name Where Certified f <br /> Plant Location _ <br /> `mar,..., r` <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 rules and guiations of the an Joaquin Local Health District. _ <br /> APPLICANT'S SIGNATURE X qa�'oor�__ - . z FA-11, 'f rA <br /> 0 <br /> FOR DEPARTMENT USE ONLY J <br /> Y <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received y a ary 3 July 1 & e eived By July 37 C <br /> BILLING REMITTANCE $ REMIT <br /> BASE- EXPLANATION DATE DATE REMITTE MOUNT DUE CHECKED <br /> �g �@ AMOUNT , <br /> FEE <br /> LESS <br /> PRORATION <br /> { <br /> PLUS i <br /> PENALTY <br /> I <br /> OTHER <br /> P <br /> OTHER <br /> Received by Date - Receipt No. Permit No. lissuande Date Mailed. e4ivered _ <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 J <br /> I <br />