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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District . . <br /> yBusiness Name (DBA) 6� s:r . Address <br /> z Owner el,/" T' t4'4 ��''+` - Address <br /> a <br /> U Firm Partners, Addresses and Telephone Numbers <br /> 4 ""6 Telephone No. "" " 2z 'r Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) _ %� dw -- _ Title ' n Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information lr <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.!0'PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <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 Location Test Date/Time i <br /> 4. M—SANITATION PERMIT <br /> Job Address/Location <br /> Owner e jaa Address <br /> SEPTIC TANK —EYCESSFOOL— :LEXCHING FIELD USEEPAGE PIT ❑ PACKAGE-PLANT <br /> Q_PERMANENT ❑ TEMPORARY 6-NEW ❑-REPAIR J 1:3 OTHER <br /> 5. ❑ CHEMICAL rTOILETS For July 1, -June 30, 19 <br /> Type Construction l--Disposal-s f <br /> No. of Units - _ Equipment Storage/Cleaning Location(s) <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 l <br /> Operator Name I Where Certified- <br /> --- - -- <br /> Plant Location " k <br /> Plant Capacity '> No. Units Served` <br /> 7. ❑ LAUNDRY For July 1, -J;une 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 County <br /> ordinances, state laws; and rules and regujations of the 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 /> BILLING RFMITTANCP""' -- $`__--,.',. `=�`'"REMIT• <br /> BASE -.-EXPLANATION AMOUNT DUE CHECKED <br /> PATE DATE REMITTED <br /> C AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by ssudLnce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> r. <br />