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lications Will Be Processed When Submitted roP t <br /> APP APPLICATION <br /> - (For Non-TranslM�NTAL HEALTH PERMIT le) SE=pTAGE � <br /> * ENVIRON _ <br /> LIQUID WASTEa3 <br /> Loc [: Distric <br /> a <br /> business in the jurisdictional area of the San Jo p <br /> Application,is he��bY rrrad o rrY Address <br /> F Business a (DBg �O A Address �" <br /> z Owner <br /> ane Nu bers Emergency Telephone No. <br /> 2 Firm Partners, Addresses and Telep <br /> a. Business Telephone No. Date. <br /> _JContractor Licence No. :Title, <br /> a=F <br /> LApplicants Name (Print) <br /> Please check Applicable Category (1-T1 and Fill in the Required Information. <br /> 1 ❑ TRATION PUMPER VEHICLE PERMIT REGISipOpo <br /> Disposal eAH sEHICL 9j <br /> �.3-t..� <br /> } ' <br /> For July 1, June 30,19 <br /> Color)� CAL.License 1Renewal No. <br /> Description(Make/Yr', CAL. License No. ""!" i O - <br /> r Serial No. Ir- <br /> { Gal.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> 2 ❑ PUMPER YARD <br /> I9 <br /> For July 1,_ June 30, <br /> No. of Vehicles Stored . 1 <br /> ` No. of Chemical Toilets Stored <br /> 3, C3PERCOLATION TEST R.S.Or R.G.E.No. <br /> R.S, or R.C.E.Name Test Date/Time <br /> Test cation n� / 0. r <br /> a, SANITATION PERMIT' /V f / <br /> b Addre s/Loc do ;N r• G Address ❑ PACKA P T <br /> r Owner ❑ CESSPOOL` "LEACHING FIELD SEEPAGE PIT ❑ OTHERi <br /> ❑ SEPTIC TANK ❑ NEW REPAIR <br /> ❑ PERMANENT ❑ TEMPORARY , <br /> F C) CHEMICAL TOILETS For July 1,-June 30, 19 <br /> 5. _-Disi�saI-Sit_"" <br /> Type Construction gF -� <br /> Equipment�Storage/Cleaning Locations) <br /> No. of Units , June 30, 19 <br /> 6, ❑ PACKAGE TREATMENT PLANT For July 1i- Where Certified <br /> Operator Names i <br /> >Y <br /> t ,Plant Location i - � 1-� .I No. Units Served y <br /> Plant Capacity <br /> T ❑ LAUNDRY For July 1,�,-June 30 More 1,000 Sq. Ft. <br /> ❑ <br /> SIZE: Less Than 1,000�q" Ft.,. <br /> j c <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MD. { i <br /> his ap lication and that the workwilf a done in :. <br /> with San Joaquin Count <br /> I hereby certify that I have prep ns o -Local ;th District. <br /> reg ytl <br /> ordinances, state laws, and ru ;- (y� <br /> APPLICANT'S SIGNATUROX <br /> ", <br /> - FOR DEPARTMEWT USE ONLY <br /> 1 &Received By.Janu!y 31 <br /> 1 &Received B July 3t <br /> ik ❑ January REMIT <br /> Fee IS DU@: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> $ AMOUNT DIfE CHEGi(ED <br /> 4 BILLING REMITTAREMITTED t AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> i If C , <br /> FEE . <br /> LESS . <br /> PRORATION <br /> PLUS , f <br /> PENALTY .t } r•�,� <br /> OTHER <br /> t <br /> e <br /> OTHER <br /> a�" -- } <br /> 1 Mailed. Delivered <br /> }! Permit No issue a Date I CA 95201 f� <br /> Received by <br /> Date Receipt No. 1601 E.HAZELTON AVE4 P.O.Box 2009 STOCKTON, <br /> APPLICANT—RETURN ALLCOTO: ENVIRONMENTAL HEALTH PERMIT/SERVICE <br />