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.� APPLICATION <br />") (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> ~ LIQUID WASTE <br /> Application is hereb made to carry/on'business in the jurisdictional area of the San Joaquin Local Health Dis rict - <br /> �Business ame (DBA) /�4 ;L �eo4 .t[ �4QSoc s'�P�S E � r-� <br /> Owner ; �„� K <br /> _ Address <br /> —� Address <br /> Firm Partners,Addresses an el hone -mbe <br /> Business Telephone No. /� — — <br /> Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category(1-nand Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REDISTRATION(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. hemical Toilets Stored <br /> 3. PERCOLATION TEST <br /> R.S. or R.C.E. Name Z'-1 �ci�tl 2 e.tJ R.S.or R.C.E No. <br /> Test Location & w7qeeorOW /1 'ro est Date/Time �S YY s <br /> 4. ❑ SANITATION PERMIT Nq�(ot v �QQ• 1'0~. <br /> Job Address/[I pion <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 <br /> Plant Location <br /> Where Certified <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. s <br /> I hereby certify that 1 have prepared this ap c ion and tha the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regula s of the S aquin Local Health District. <br /> APPLICANT'S SIGNATURE X J <br /> FOR DEPARTMENT USE ONLY �- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH C3 January 1 6 Received By January 31 ❑ July 1 Received By July 31 <br /> T <br /> BASE EXPLANATION BILLING EMITTANC s REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE - --— - —� -— — - AMOUNT <br /> LESS -- i�Z• Y” J <br /> PRORATION <br /> PLUS <br /> PENALTY V{ <br /> OTHER <br /> OTHER J <br /> Received by Dote Recei t No. <br /> . P Permit No. Issuance ate Mailed Oe 14ered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL"FAUN PERMIT/SERVICES 1001 E.HAZELTON AVE.,P.O.Boa 20" STOCKTON,CA 96201 <br />