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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) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application ' he eby made t rry Qn business in the jurisdictional area of the San Joa uin gal Health District <br /> Business Name DBA)_ ��t��c s AALQ()4?_ L-li t�Address-p ��� 0-0 t` <br /> aOwner i)Q �� i�C7 fry Address zvc <br /> Firm Partners, Addresses and Telephone Nu ers <br /> aBusiness Telephone No. j Emergency Telephone No._geo 6,7 <br /> Contractor Licence No. <br /> Applicants NamTitle ( lie Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For JUIy 1, June 30,19`- Disposal Sites - <br /> Description(Make/Yr., Color) <br /> Serial No. _ CAL. Licen— <br /> se No "~^ CAL. License Renewal No. <br /> Capacity .:Gal., Weights & Measures..No. � <br /> Equipment Parking Address .. <br /> 2. ❑ PUMPER YARD v ' <br /> For July 1, June 30, 191 <br /> No. of Vehicles Stored 4- m. ` <br /> No. of Chemical Toilets Stored a <br /> 3. ❑ PERCOLATION TEST -- <br /> R.S. or R.C.E. Name R.S. or R.P.E. No. <br /> _ - <br /> Test Location TestLLDate/Time _ <br /> 4:` ❑ SANITATION PERMIT��, - a <br /> Job Address/Location <br /> kw - 0 <br /> ner Address iSEPTIC TANK 13CESSPOOL LEACHING FIELD 11SEEPAGE PIT ❑ PACKAGE PLANTItri .1 <br /> (' ❑ RARYNEW REPAIR �Ef-OTHER � �X �J <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 - <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 <br /> r <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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Vo. <br /> I-hereby certify that I have preparijthi.,,applications nd that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule$`/`d•, ons of t Saq m Local Health District. <br /> i APPLICANT'S SIGNATURE X <br /> 4 <br /> FOR-DEPARTMENT USE ONLY <br /> Feels Due..❑ ANNUALLY ❑ PER UNIT ❑ PER SITE - ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLItJG- REMITTANCE SREMIT <br /> BASE EXPLANATION DATEY— y DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS s <br /> PRORATION " <br /> PLUS C— <br /> PENALTY,', <br /> OTHER <br /> OTHER <br /> ~'' r—»�• <br />' r Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> °G <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Bim 2009 STOCKTON,CCS;!6j�_,y. <br />