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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) SEPTAGE <br /> a ENVIRONMENTAL HEALTH.PERMIT <br /> LIQUID WASTE <br /> Application is he b made to car on business in the jurisdictional area of the San.Joaquin Loc*Heal �' i <br /> yBusiness Name (DBA) WAddress•,_ti - <br /> a Owner _ ..___ � ,._,- <br /> Address zb. <br /> Firm Partners, Add esses and Telephone Numbers <br /> CL Business Telephone No. - 'A 1.. .. -..Emergency Telephone No., <br /> Contractor Licence No. <br /> LAppiicants Name (Print) t - Title, Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information _ ;;!I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACHVEHICLE) z, <br /> For July 1;�- - -June 30,19---— - Disposal Sites- - <br /> Description(Make/Yr„ Color) <br /> Serial No. ;N r CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD I. <br /> For July 1, June 30, 19' <br /> No. of Vehicles Stored ifi <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST` <br /> R.S. or R.C.E. Name �y R.S.or R.C.E. No. <br /> Test Location'— I Test Date/Time p' <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> SE <br /> 9—SEPTIC ANK CESSPOOL LEACHING Ftl£LD 'SEEPAGE PIT ❑ :PACKAGE PLANT <br /> tV?IFRMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER "S <br /> # . <br /> 5. CHEMICAL TOILETS For July 1,-June 30, 19 ° <br /> `Type'Construction Disposal Site <br /> No. of Units .I' Equipment Storage/Cleaning Location(s) I t y <br /> 6. ❑ PACKAGE TREATMENTjPtANT For'July 1, -June 30, 19 <br /> Operator Name N' a Where Certified <br /> Plant Location d I <br /> is <br /> Plant Capacity �I' # No. Units Served <br /> 7: ❑ LAUNDRY For July 1, -'June 36 19 - <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 have prepared this applicat' that the work will be done in accordance with San Joaquin County i <br /> ordinances,state laws, and r les a regulations f t S n Joaquin Local Hiea0.District. t <br /> APPLICANT'S SIGNATURE X - i = <br /> CZ <br /> 1"L ',FOR DEPARTMENT USE ONLY <br /> d <br /> Fee Is Dile: 11 ANNUALLY] _. .❑ PER UNIT El PER SITE ❑ EACH ♦� ❑ January 1 &Received By January 31 El July I &Received By July•31` <br /> r ' - t 4 4 REMIT t <br /> BASE EXPLANATION BILLING _ REMITTANCE AMOUNT DUE ,,..- CHECKED',,, <br /> DATE", -•DATE 'S'. —REMITTED - .� - AMOUNT. .. <br /> LESS <br /> ' t <br /> EEE <br /> e <br /> LESS <br /> 4 <br /> PRORATIONPLUS <br /> - <br /> ¢,.. <br /> PENALTY r q <br /> OTHER - :;. - - - - -•- {- - <br /> OTHER <br /> Received by Date - Receipt No. Permit No, - -issuance Date - Delivered` 3 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAXEITON AVE.,P. oz 009 STOCKTON,CA 95201"— <br /> t <br />