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AL. <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Slgn=?he-Applicalion�_�.. <br /> APPLICATION -TM : <br /> (For Nan-Transferable, Revocable, and Suspendable) <br /> rSEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of than Joaquin Local Health District <br /> FBusiness Name (DBA);� ,>� <br /> z Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 5. Business Telephone No. V6 C.—9,6 dp� Emergency Telephone No. <br /> Contractor Licence No. Z <br /> t <br /> L Applicants Name (Print) T" L Title Ate— 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 July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) r <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> t <br /> Capacity Gal:,Weights & Measures No. � <br /> F Equipment Parking Address i <br /> 2. ❑ PUMPER YARD I� <br /> For July 1, June 30, 19 i <br />! No."bf Vehicles Stored I� <br /> No..of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Loc on <br /> Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location 70_701 <br /> �o S <br /> Owner _ Address cam.+ csJd <br /> E SEPTIC TANK E] CESSPOOL 13FI <br /> LEACHING ELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT ,J <br /> i BPERMANENT ❑ TEMPORARY ❑ NEW 2 REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 a <br /> j Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> ti. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 j <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 I� <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I hyfe.preparehis appl'cation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws rules a ,regu s of a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X j <br /> FOR DEPARTMENT USE ONLY 1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> I <br /> BASE EXPLANATION KILLING REMITTANCE $ REMIT <br /> DATE HATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ' Ste ' T CSO <br /> LESS T J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. rssuancib Date - Mailed Delivered <br /> + APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> r it <br />