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Applications Will Be Processed When Submitted Properly Completed. Be ure o Ign <br /> APPLICATION i <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> j ENVIRONMENTAL HEALTH PERMIT j <br /> LIQUID WASTE <br /> Applicata 's hereby made ar on business in the jurisdictional area of the oaquin�L�oca�a [� r t r I <br /> �� ��/- Address ��JJ <br /> to Business Name (DBA) <br /> IIII <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers I <br /> Q. Business Tel <br /> No. <br /> �3 Z Emergency Telephone No. <br /> Contractor Licence No. O S 6"Title <br /> C r <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required In ormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)" <br /> For July 1, June 30, 19 Disposal Sites E <br /> Description(Make/Yr., Color) ; <br /> Serial No. <br /> CAL. License'No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. ' <br /> 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. <br /> R.S. or R.C.E. NameI <br /> Test Date/Time' <br /> Test Location ' <br /> 4. ❑ SANITATION PERMIT �1 C <br /> Job Address/Luca on <br /> 6r Address r <br /> Owner LEACHING FIELD ❑ SEEPAGE'PIT'""❑`PACKAGE PLANT <br /> 11 SEPTIC TANK ❑ CESSPOOL ❑ OTHER; <br /> C1 PERMANENT 13 'SG'TEMPORARY ❑ NEW REPAIR (�4-.' �09f <br /> June 30, 19 <br /> : <br /> 5. ❑ CHEMICAL TOILETS For July 1, - - ;- <br /> Disposal Site. <br /> Type Construction <br /> Equipment Storage/Cleaning Locations) <br /> No. of Units <br /> i <br /> I O-•P�PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> 4 <br /> Operator Name <br /> 1 k <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19- <br /> SIZE: <br /> 9 -SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo:" <br /> I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. t , <br /> APPLICANT'S SIGNATURE X• ` <br /> ' - FOR DEPARTMENT USE ONLY <br /> _ Fee lS DUe: ❑ ANNUALLY PER UNIT PER SITE ❑ EACH­ ❑ January 1 &Received By January 31 '❑ July,1 &Received By July 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASF EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE �] <br /> I LESS <br /> t PRORATION _ <br /> PLUS OF <br /> PENALTY - -{0 <br /> OTHER C (tJ�+ <br /> k <br /> OTHER .. _ <br /> Issuanc¢➢ate Mailed Delivered <br /> - Date - Receipt No. Permit No. <br /> R¢ eived by 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 <br /> APPLICANT—RETURNALLCOPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES �"' <br />