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roperly <br /> Applications Will Be Processed When SubAmPilP� iCAT`ONpleie a ure <br /> �- <br /> r ' <br /> (For Non-Transferable, Revocable,and Suspendable Y SEPTAGE <br /> =� 4 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl icatior hefby de to carry busin?.ss in the jurisd' tional area of th an��aquin�Localealt i rict <br /> Address` f <br /> w Business Name (DBA) <br /> Address <br /> q Owner <br /> J Firm Partners, Addresses and Telephonero uJn�ers Emergency Telephone No. <br /> aBusiness Telephone No. <br /> j Contractor Licence No. ! Title Date �� <br /> 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 W <br /> kDescription(Make/Yr., Color) CAL. Lic-ise Renewal No. <br /> t Serial No. CAL. License No. ` <br /> Capacity Gal., Weights &Measures No. <br /> E 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 R.S. or R.C.E.No. 1.4 <br /> R.S. or R.C.E. Name Test Date/Time <br /> Tes L cation _ <br /> 4. Pi SANITATION PERMIT �1�� 0 � >'`f <br /> d Job Addr s/Location � �� <br /> Owner Address <br /> 11 SEPTIC TANK El CESSPOOL <br /> ' LEACHING FIELD SEEPAGE PIT 1:1 PACKAGE PLANT ��rr <br /> 13 PERMANENT ❑ TEMPORARY [3 NEW IRREPAIR A OTHER J-r fT 511V�b�- C <br /> 5. 11 CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site <br /> Type Construction <br /> I Equipment Storage/Cleaning Location(s) <br /> No. of Units <br /> j B. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity. <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 /> f <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r and regul tns of e S .Jo q 'n Local Health District. <br /> k � <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> PER UNIT ❑ PER SITE El EACH ❑ January 1 &Received By January 31 E] July 1 &Received By July 31 <br /> Fee Is Due: 13 ANNUALLY 11 <br /> REMIT <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> 1 <br /> FEE <br /> LESS <br /> PRORATION <br /> d PLUS <br /> PENALTY e <br /> OTHER <br /> i, OTHER F <br /> 4 x V Delivered <br /> Receipt No Permit No. <br /> Issuance Date ailed <br /> Received by Date .-Box 2009 STOCKTON,CA 95201 <br /> 1601 E.HAZELTON A, <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES — <br />