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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 /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is ereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,F Business Na (DPA) Address °r <br /> f z Owner Address <br /> a <br /> I J Firm Partners, Addresses and Telephone mbers ,{ <br /> aBusiness Telephone No. � ���3 Imo" Emergency Telephone No. <br /> Contractor Licence No. <br /> Lx Applicants Name (Print) Title Date <br /> Please check Applicable Category(11-71-and Fill in the Required Information . CLAREI,XPS SEP jC & SLIVER SERVICE <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 263 So. Oro �, Stock'on, Ea;lf. 9520.5 <br /> For July 1, June 30, 19 Disposal Sites �'!t•4i � '� S <br /> •'r � <br /> Description(Make/Yr., Color) - <br /> t Serial No. CAL. License No. CAL, License Renewal No. <br /> t 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 /> k 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E,Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. )4 SANITATION PERMIT <br /> Job Address/Loc tion <br /> Owner <br /> o�� �•t/ � - Address <br /> SEPTIC T NK 13 CESSPOOL LEACHING FIELD . WSEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW REPAIR �OTHE <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> I 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 /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> e SIZE: 13Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. `4 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 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 les d regulations of the n Joaq Local Health District. <br /> f C}...�;RL',; SEPTIC ! c�y)Ir ;'� <br /> APPLICANT'S SIGNATURE X Camrra SEPTIC� F� 7/.� <br /> L 2`3 �•tii. C�ro 11 Stuck,S]n, C'a'lf, S52G5 <br /> 6 IG-E 7�.-yf 10, <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due:'[:] ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION t-BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE 671 DATE REMITTED AMOUNT <br /> �Sa ... <br /> LESS <br /> PRORATIONPLUS <br /> P PENALTY `,}� <br /> l4 6k— N L r,-,2 C <br /> OTHER <br /> OTHER <br /> tT <br /> t Received ty Dae Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 JJ' <br />