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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> :r (For Non-Transferable, Revocable,and Suspendable) <br /> � - SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 44�. LIQUID WASTE <br /> Application I ereby mad o car o uslness In the jurisdictional area of th n aquin Loc Health District _ <br /> Co-Business Name (DBA) �� Address QS <br /> I z Owner ..:•::.., -_ ..,. . Address <br /> 1 Firm Partners,Addresses and Tele ho a <br /> �7 Emer Numb rs <br /> "' � <br /> K Business Telephone No. gency Telephone No. <br /> Contractor Licence No. IL-z—g - Y t <br /> Applicants Name (Print) Title„ v T Date Q <br /> i Please check Applicable Category (1-7)and Fill in the Required Information <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. LII CAL. License No. CAL, License Renewal No. <br /> Capacity I� Gal„ Weights & Measures No. <br /> - <br /> Equipment Parking Address h <br /> 2. ❑ PUMPER YARD <br /> I <br /> For July <br /> No. of Vehicles Stored �i { <br /> f NNO. of Chemical Toilets Stored ' <br /> 3. ❑'PERCOLATION TEST <br /> R.S. or R.0 E.Name_ R.S. or R.C.E. No. <br /> Test ocation, S Test Date/Time <br /> 4. 0SANITATION PERMIT 41 <br /> Job AddressLLocation <br /> a <br /> Owner r� Address <br /> 11 SEPTIC TANK ❑ CESSPOOL K(.LEACHING FIELD ALSEEPAGEPIT ❑ PACKAGE PLAN <br /> ❑ PERMANENT : } ❑ TEMPORARY ❑ NEW )XREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS Fpr July 1, -June 30, 19 <br /> Type Construction I� Disposal Site <br /> No. of Units Equipmer Storage/Cleaning Location(s) <br /> 6. 11 PACKAGE TREATMENTRyLANT For-July 1, -June 30, 19 _ `A <br /> .P a t. <br /> . Operator Name r' - Where Certified{"�• <br /> Plant Location <br /> t Plant Capacity s(�' 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 U'sed/Amount/Mo. <br /> k. I 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, and rules and r gulation the San Joaquin Local Health District. ' <br /> APPLICANT'S SIGNATURE X <br /> — e }. <br /> l - FOR DEPARTMENT USE ONLY , <br /> Fee IS Due: ❑ ANNUALLY `I_ ❑ PER UNIT 11 PER SITE El EACH ❑ January 1 &Received By January 31'' J Cl July 1 &Received By July 31 <br /> BILLINGREMITTANCE $ ' REMIT <br /> BASE ` EXPLANATION AMOUNT DUE CHECKED <br /> v- +� 'L q -DATE DATE REMITTED <br /> AMOUNT <br /> t t ) .�FEEy `f t7 AO <br /> LESS . t l <br /> PRORATION - <br /> PLUS ;. <br /> PENALTY - - - <br /> f <br /> OTHER <br /> OTHER i. €. "%`�+r <br /> Received by Date Receipt No, + i.Permit ,-suanc -13a `• ..Mailed red <br /> APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL EALTR PERMIT/SERVICES*' i{1601 E"HAZELTON AVE.,P.O.Box 200 STOCKTON,CA 95201 <br />