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Applications Wlill Be Processed When Submitted Properly Completed. Be SureTobign InewPPrn,auv-•. <br /> APPLICATION <br /> (For Non-Transferatile, ReYoeable,and Suspendable) SEPTAGE <br /> 41"` ENVIRONMENTAL HEALTH.PERMIT <br /> LIQUID WASTE <br /> Application is hereby:made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Address 1�1` h'14 <br /> y Business Name (DBA) <br /> z Owner �M Address <br /> a I: <br /> j Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> aBusiness Telephone No. ^ ° 97/ �h <br /> Contractor Licence No. Z i. 'y3 - Z <br /> Title_. Date <br /> 4L Applicants Name (Print) 4 <br /> Please check Applicable Category(114)and Fill in the Required Information ._ is '._ ," �•. <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Disposal Sites - <br /> 'For July 1, June=30, 19 _-.. <br /> Description(Make/Yr., Color) qli __ <br /> Serial No. <br /> GAL. License No. CAL. License Renewal <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD �f <br /> For July 1, June 30, 19 If <br /> No. of Vehicles Stored �N <br /> No. of Chemical Toilets Stored II <br /> 3. ❑ PERCOLATION TEST, R.S. or R.C.E. No. <br /> R.S.or R.C.E. Name ) i <br /> Test Location - Test Date/Time <br /> 4. 0 SANITATION PERMIT <br /> Job Address/Location 1 <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ;k LEACHING FIELD c SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 PERMANENT ❑ TEMPORARY ❑ NEW �+ REPAIR ❑ OTHER a <br /> 5. ElCHEMICAL TOILETS For July 1, -June 30, 19 i <br /> Type Construction " 1.11. . Disposal Site <br /> No. of Units 11 Equipment.Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 where Certified <br /> Operator Name 4. <br /> Plant Location I� <br /> Ir 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. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. y <br /> M sc r..rr ^ihe,ger;Erma^ec of the�n ask".or whic`I tHs permit'is issued,t s`lail not employ any persc' <br /> Horn aovtner--rlcn S�rrt-"�, as <br /> in su(:b rnannot aS to CecG:!tL' . <br /> Contractor's hiring 3r S .1•l Ct:lily``a:ill the periGrf7i ai a ul Lhe%vort foirwhiC ihls per nits issi ed,t shall <br /> employ persons Sur., ::pe,;�lil, <br /> OIL_ (i <br /> I hereby'certify that I hve�prepared this applica' and that the work wiH be done in accordance with San Joaquin CoGo <br /> ordinances, state laws,!fand rules and regulationAr <br /> of the 5a Joaquin Local Health District ; �, <br /> ti <br /> APPLICANT'S SIGNATURE X ryI <br /> O7X7! f <br /> j} pill . FOR DEPARTMENT USE ONLY .��- <br /> Ii1 ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedJuly 31 <br /> Fee IS DUE: ❑ ANNUALLY PER UNIT REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE' EXPLANATION , DATE K DATE REMITTED AMOUNT <br /> FEE IP4 q < <br /> LESS <br /> PRORATION' y <br /> PLUS .. - <br /> PENALTY <br /> I _ <br /> OTHER ] <br /> OTHER n x <br /> 4 i6c­, �. <br /> Received by Dare Receipt No. <br /> Permit No. I once D e Mailed Delivered <br /> 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201' <br /> APPLICANT—RETURN ALL C I�PIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES v <br />