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" Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The-Application. _ <br /> _ APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE _ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to car on bu i ess in the jurisdictional area oft Sa j)oaq,�u`ln+ocal Healt�Dls <br /> L. Address���`-' "`-' C-`-' <br /> yBusiness Name (DBA)L- �- <br /> z Owner e �� - _ Address y <br /> a <br /> J Firm Partners, Addresses a elephone Numbe s <br /> aBusiness Telephone No. Emergency Telephone No.S <br /> Contractor Licence No. L - i <br /> Title Date <br /> L Applicants Name (Print) - -- <br /> 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 f <br /> Description(Make/Yr,, Color) _ _ <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> f <br /> 1 <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 - r No. of Vehicles Stored {� <br /> No. of Chemical Toilets Stored 1 <br /> 3. ❑ PERCOLATION TEST , <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location 4 W Test Date/Time r <br /> 4. ❑ SANITATION PE I O ) <br /> Job Ad ss/Location <br /> O er CAddress <br /> SEPTIC TANK ' ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT 13 PACKAGE PLANT <br /> PERMANENT "�❑ TEMPORARY I G EW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plana Capacity 3 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 Used/Amount/Mo- - <br /> hereby cert' t 1 have pr par .;this applicatio and that the work will be doe in accordance withWSan Joaquin County <br /> ' ordinances, state Ia , nd r le an regulation of San oaquin Local Health District <br /> '-A P <br /> PLICANTS <br /> APPLICANT'S SIGNATOR <br /> t e <br /> _ FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31. ❑ July 1 &ReceivedREMITuiy 31 <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> - DATE DATE REMITTED AMOUNT <br /> �sl° <br /> FEE _ <br /> LESS i"T <br /> PRORATION - <br /> PLUS <br /> i PENALTY <br /> OTHER <br /> OTHER <br /> 9 Received by ate Receipt No, Permit No.. -- Issuance Date.v= "Mailed DOivered , <br /> I, _ -----• -� fir-1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON;CA 45201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERICES'- <br />