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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> - APPLICATION SCANNED <br /> (For Non-Transferable, Revocable, and Suspendable <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUIB WASTE <br /> Applicat n/' hereb%�ade army s in the jurisdictional area of the o in Local Heal istrict <br /> y Business N me (DBA) Xr} (' h� (//� /�r},1 <br /> 1- Owner i I Adtlress J i z 1 0>C l i z/4/z/V 2 r�y <br /> Ad res P /^ <br /> Firm Partners, Addresses and ele h ne Numbers <br /> Q. Business Telephone No. f <br /> d Contractor Licence No. Emergency Telephone No. `^ <br /> Applicants Name (Print) Title ��/ /� <br /> Please check Applicable Category Date <br /> g ry (1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 <br /> Description(Make/Yr., Color) Disposal Sites <br /> Serial No. CAL. License No. <br /> CapacityCAL. License Renewal No. <br /> 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. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT _ <br /> Job Address LLocatii n/., �r,, - <br /> ,Ow ✓/ . 't/�-L'� Address <br /> L� SEPTIC TANK ❑ CESSPOOL ACHING FIELD ❑ SEEPAGE PIT 11 PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site L I <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 . 7 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> v <br /> I hereby certify that I have is application and hat a work '11 be done in accordance with San Joaquin County <br /> ordinances,state laws, and ules r4-regulations of the S Jo uin L istrict. <br /> APPLICANTS SIGNATURE X <br /> v� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receivetl 9y January 31 ❑ July i a Receivetl By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> pp AMOUNT <br /> 4 <br /> FEE 45 O_ <br /> LESS C✓ <br /> PRORATION <br /> PLUS �vj <br /> PENALTY <br /> OTHER <br /> OTHER <br /> D ( �7 <br /> Receive0 by Data Receipt No. Permit o. I suenc DateFaileI e <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON E2009 STOCKTON,CA 96201 <br />