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Applications Will Be Processed When SubAlmPitiPe�ICATIONProperly pleted. Be Sure <br /> Toulign ino <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> I x cv\\ ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio�is hereby made to carry on business in the iurisdictional area of the San Joaquin Li Health District. � <br /> /VC $eal Address <br /> .n Business Name (DIBA) Address " <br /> ` 1 <br /> a Owner <br /> J Firm Partners, Addresses and Te ponIII _e Numbers �M Emergency Telephone No. <br /> a Business Telephone No. 11111" — lop <br /> aZ <br /> Contractor Licence No. �1l <br /> Title ate <br /> L Applicants Name (Print) CLAPENOE'S SEc"I C r': --vl;1t o ' i{CE <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 263 So: Oro v 5toc',I C•iif. 95205 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEI`HIICLE) E rc <br /> Disposal Sites.€` '" 1 <br /> For July 1, June 30, 19 I <br /> Description(Make/Yr.,Color) I. CAL, License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights &Measures No. 4� <br /> k Equipment Parking Address. <br /> 2. [1 PUMPER YARD <br /> For July 1, June 30, 19 <br /> No, of Vehicles Stored LINo. of,Chemical Toilets Stored <br /> 3, ❑ PERCOLATION TEST R.S.or R.C.E. No. <br /> 1 <br /> R.S. or R.G.E. Name �r Test Date/Time <br /> Test Location <br /> l 4. WSANITATION PERMIT <br /> Job Addr ss/Lo a on Address ` <br /> ,ner 13 PACKAGE PLANT <br /> SEPTIC TANK 13CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ OTHER <br /> PERMANENT <br /> C] TEMPORARY ❑ NEW El REPAIR <br /> g. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 i <br /> Type Construction _ <br /> Disposal Sitel: <br /> f No. of Units Equipment Storage/Cleaning Location(S) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19`, Where Certified <br /> E Operator Name <br /> I Plant Location <br /> .No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30; 19 <br /> I` SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. ' <br /> Ft. <br /> E3 DRY CLEANING,Chemicals Used/Amount/Mo. <br /> kM <br /> I <br /> 4 <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and regulations of the IIIIIIIIIIII�San Joaqui ocal Health District. <br /> CL�, E �CE`i S 'T'C t': <br /> } <br /> ICAN SIGNATURE X `1 <br /> APPLICANT'S S G - `I111 Pkv.4�,a-:3`r'J9 Conti^.,::): .-i.•z <br /> FOR DEPARTMENT USE ONLY <br /> - PER UNIT a ❑ PER SITE h�, C1 EACH - EI January 1 &Received By January 31 ❑ July 1 &ReceivedByJuly 31 <br /> Fee IS DUB: ❑ ANNUALLY <br /> BILMIT <br /> LING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT <br /> I s <br /> FEE - <br /> LESS <br /> PRORATIONPLUS <br /> J4 <br /> 4 PENALTY <br /> ` OTHER <br /> OTHER <br /> D 31336 <br /> Date � Receipt No. ,�� Permit No. Issuance Date Mailed Delivered <br /> Received by 1501 E.HAZELTON AVE- P.O.Box 2049 STOCKTON,CA 95201 <br /> .. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH�PERMITlSERV10E5 <br /> r _ <br />