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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> APPLICATION k <br /> (For Non-Transferable, Revocable,and Suspendable) S.EPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT / <br /> LIQUID WASTE f� �n business in the jurisdictional area of-the San Joaquin Loc, Healthict I <br /> Application is hereby made to carry o } . <br /> y Business Name (DBA) V Add <br /> ress,1¢ ,��� —� <br /> z Owner _ Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> K Business Telephone No. 4 3`x.9 Emergency Telephone No.� Q_ _7+_ <br /> 1 Contractor Licence No.1- a _� . <br /> t Title Date - �� } <br /> L Applicants Name (Print) V „ ; _ <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1.,"❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) 1 <br /> -For July 1, June 30, 19 r -Disposal Sites <br /> Description(Make/Yr., Color), <br /> Serial No. CAL, License No. CAL. License Renewal No. <br /> Capacity 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 pr <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/Location <br /> Owner Address <br /> SEPTIC TANK CESSPOOL; LEACHING FIELD SEEPAGE PIT Q�PACKAGE PLANT <br /> 11,PERMANENT ❑ TEMPORARY NEW REPAIR OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, - une 30, 19 K <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 /> Operator Name ! Where Certified <br /> Plant Location t <br /> Plant Capacity 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 />'i DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done iri accordance with San Joaquin County <br /> ordinarices, state Paws, and rules and regulatio of the tdi <br /> San Jo n Local Health District. <br /> APPLICANT'S SIGNATURE X / J <br /> } FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By'January 31 ❑ Ju$y S &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - DATE DATE REMITTED AMOUNT <br /> FEEWIL <br /> - - <br /> LESS / u_ <br /> PRORATION ` <br /> PLUS <br /> PENALTY - <br /> OTHER - <br /> t - <br /> } OTHER <br /> Received by Date Receipt No, - Permit No s ante to Mailed De4ivered , <br /> APPLICANT—RETURN ALL COPIES T17:_' ENVIRONMENTAL HEALTH PERMIT/SERVICES " 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />