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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) 1 <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati s he eby ade to carRonn�b si ess in th urt/sdd'ictional area of the San Joaqui n�ocal Health District <br /> OF Business (DBA) �f`le$ "Y "� �� Address r �' `� <br /> AVR <br /> I-. Owner i✓�i AGA Address 9 <br /> a <br /> Firm Partners, Addresses and Te hone Numbers <br /> CL <br /> Business Telephone No. sn 3 Cis $ Emergency Telephone No. <br /> �-7,—�--j Contractor Licence No. �LApplicants Name (Print) ► t t/ Title Date I <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 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. ' CAL. Licc�se Renewal No. r <br /> Capacity Gal., Weights &:Measures No. h <br /> Equipment Parking Address }! <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored T- <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ± - <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Test Location Test Date/Time <br /> Q. L$SANiTAT10N PERM T o77ili�Gle- A VQ i M AA; 'eCP% <br /> Job Addre /Location <br /> Owner oft)e t 0' Address <br /> i SEPTIC TANK ❑ CESSPOOL '• LEACHING FIELD ❑ SEEPAGE PIT—❑•PACKAGE PLANT. <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR. ❑ OTHER 1 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 1, <br /> Type Construction Disposal Site ' <br /> Equipment Stora Storage/Cleaning Location(s) <br /> No. of Units9 9 <br /> i r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 r > <br /> I Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> i 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. 1 <br /> .. Twill <br /> :o/n, <br /> jv1I hereby certify that I have prepared this application and that the In accordance with San Joaquin County <br /> ordinances, state laws, Ies and regul ns of the an Joaquin Local Health District. <br /> Qx <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED, AMOUNT <br /> FEE <br /> LESS, <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER T i <br /> i <br /> r OTHER - <br /> a <br /> P � <br /> Received by - Date f Receipt No. Permit No. �.,,._ Issuance Date Mailed Delivered <br /> 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - <br />