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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The A plication. <br /> APPLICATION r <br /> (For Non-Transterabie, Revocabie,`and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH,PERMIT <br /> LIQUID WASTE <br /> Application is. r by made to c on b si in the jurisdictional area of the to Lo Di I^ r <br /> Business Name (DBA) Address <br /> z Owner ,- Address - <br /> Firm Partners, Addresses and Tel ne Numb rs' 4 <br /> a Business Telephone No. �` � iv Emergency Telephone No, <br /> Contractor Licence No. <br /> L Applicants Name (Print) K Title • s Date41 L <br /> ) <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. _,❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE),-. �t <br /> `w4' Disposal Sites <br /> For'July-1, June 30, 19 — � � R '- - <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 t I <br /> 2. ❑ PUMPER YARD,' �• 3 � ;tea-,! t <br /> For July',1, } June 30, 19 <br /> No.,of Vehicles Stored <br /> No, of Chemical Toilets Stored t `" <br /> 3. ❑ PERCOLATION TEST , <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> I ; <br /> Test cation Test Date/Time <br />! <br /> I 4. SANITATION PER <br /> Job Addr ss/ ocation <br /> O .nerAddress <br /> i SEPTIC TANK❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT .� <br /> ERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 d <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^ EWhereCerfifiedE_ <br /> Operator Name <br /> Plant Location ; <br /> Plant Capacity Y No, Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ' <br /> i SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.`«# <br /> +4 <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. - <br /> I t <br /> 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, an ules and reg iations oft n JRaquin Local Health District. <br /> DA <br /> t, APPLICANT'S SIGNATURE X 4 <br /> r FOR DEPARTMENT USE ONLY <br /> I <br /> Fee Is DUE: ❑ ANNUALLY ❑ PER UNIT PER SITE - C1 EACH ❑ January 1 8.Received By January 31 ❑ July 1 8 Received 8y July_31 <br /> REMIT <br /> BASE EXPLANATION BILLING i' REMITTANCE AMOUNT DUE CHECKED <br /> . DATE -_': DATE. -r REMITTED- AMOUNT <br /> t FEE A <br /> e� <br /> LESS <br /> PRORATION <br /> PLUS _ r6U. I(I.�fiJ l �0 <br /> PENALTY------------- <br /> _ <br /> OTHER <br /> OTHER - ! . ZU <br /> fV..!�,�ved by Date Receipt No. Permit No _ Issuance ate Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Bos 20119 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />