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Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTheApplication. i <br /> APPLICATION <br /> (For Non-Transferable;Revocable,'and Suspendable) <br /> SEPTAGE <br /> �� ENVIRONMENTAL HEALTH_ PERMIT <br /> LIQUID WASTE <br /> Application is hereby ade to carry on business in the jurisdictional area of the San.Joaquin Local Health District <br /> F Business Name {DBA) - r Address N" <br /> .» <br /> aOwner Address <br /> J Firm Partners, Addresses and Telephone Numbers �. <br /> CL <br /> Business Telephone No. 7�- �^ s Emergency Telephone No. <br /> Contractor Licence No. s FI'3 2 1 <br /> 4 <br /> Applicants Name (Print} c-2. _ Title Date � :6 ` <br /> Please check Applicable Category (1-7) and Fill in the Required,lntormation <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_ ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. t <br /> Test Lo ation Test Date/Time <br /> i <br /> 4. tiQ SANITATION PERMIT <br /> Job Address/Location <br /> I O�,w�er ,r�G Address— �`��" / .� J, ..0// 1 !mac `f3 <br /> u SEPTIC TANK C1CESSPOOL PCEACHING FIELD C1SEEPAGE PIT ❑ PACKAGE PLANT ! <br /> i ❑ PE4ANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. 0,CHEMICAL TOILETS For July 1, -June 30, 19 v s f I <br /> Type Construction Disposal Site ' + 1 } r <br /> No. of:Units c Equipment Storage/Cleaning'Location(s) tr <br /> 6. ❑IPACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> t Where Certified <br /> Operator Name - - - � ; <br /> Plant Location <br /> Plant Ca acitY k No. Units Served <br /> p <br /> 7. ITLAUNDW For July 1, -June 30, 19— <br /> SIZE: , <br /> 0, 19 SIZE: i ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. z f <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> hereby certify that I. have prepared this application and'that the ork will b4 one in <br /> ac�rdance with San Joaquin County <br /> ordinances,state laws, and rules and reg lations of the San Joaquin,Local Health Districta�-'t <br />` APPLICANT'S SIbNATURE X <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> t <br /> Fee Is Due:`❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH' I7 Ja'cLuary 1 &Received By January 31 ❑ July 1 Received By July 31 <br /> i s <br /> REMIT;. <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION t AMOUNT DUE CHECKED <br /> s _ DATE - .DATE - 4RE} ITTED. - AMOUNT <br /> I FEE �S/ { ^1 - .e._. f. 4 <br /> LESS <br /> PRORATION I aIJ <br /> PLUS { c } <br /> PENALTY ' { <br /> OTHER ~ 3 _ . .. - 3 t <br /> OTHER .: <br /> Received by Date Receipt No. Permit No. ' e Issuance to Mailed Delivered_ +. <br /> 1601E.HAZELTDN AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT-RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES .. <br />