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Applications Will Be Processed-When Submitted Properly Completed..-Be Sure To Sign The Application. <br /> APPLICATION - - <br /> �"' w (For Non-Transferable, Revocable, and Suspendable) " T_ <br /> .SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQuio.WASTE <br /> a­Application is by made to capry on busiagssin the jurisd tional area of the San Joaquin Local Health D1 Ict ; <br /> rn Business Name []BA) �G- ` ddress� <br /> Address z <br /> y. � Owner a-^� - - -• <br /> L Firm Partners, Addresses and!Telephone Numbers = <br /> d Business Telephone No. 3ll� -��S Emergency Telephone No. <br /> a „i n, - <br /> Contractor Licence No, <br /> Applicants Name (Print) Title Date <br /> Please check Applicable and Fill in the Requl d Information <br /> I PP Category 9 ry (1-7) <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30,19 Disposal Sites l �' <br /> Description(MAke/Yr., Color) v x 4 <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. r <br /> -=Equipment Parking Address r ; <br /> 2. ❑ PUMPER YARD Y �` <br /> For July 1, June 30, 19 <br /> -No, of Vehicles Stored E. <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 ation -Test Date/Time <br /> 4. _ SANITATION PERMIT <br /> Job Address/Location <br /> Owner - Address 3 21 <br /> ❑SEPTIC TANK CESSPOOL' LEACHING FIELD ` ®� EPAGE PIT ❑ PACKAGE PLANT <br /> 13 PERMANENT ❑ TEMPORARY ❑:NEW PAIR ❑OTHER a <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30,'19 #6 <br /> Type Construction Disposal Site x <br /> No. of Units Equipment Storage/Cleaning Location(s) I <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name-- Where Certified <br /> .Plant Location a <br /> _ I <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30,19 <br /> '.SIZE:. ❑ 'Less Than 1,000.Sq. Ft., ❑ More SThan.1,000 Sq. Ft <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo:- <br /> - _ l <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,'state laws, and rules and gulations of the San Joaquin Local Health District- <br /> APPLICANT'S SIGNATURE X' , <br /> -� FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ' ❑ PER-SITE. ❑ EACH '❑ January 1,&- ed By.January 31 '_- ❑ July 1&Received By July 31 - <br /> -- - ---- REMIT - <br /> BILLING REMITTANCE $ <br /> - BASE _ EXPLANATION AMOUNT DUE'- CHECKED r <br /> DATE- DATE REMITTED r AMOUNT " <br /> FEE <br /> _ LESS <br /> 3 <br /> PRORATION <br /> PLUS <br /> . . PENALTY <br /> OTHER <br /> - <br /> OTHER _ - r . <br /> €:.: <br /> _Received by -Date v ceipt No- Permit No. _ Issuance Date Paller, 0 Delivered... <br /> APPLICANT—RETURN ALL COPIES TO: �ENVIRONMENTAL HEALTH PERMIT/SERVICES ,--. ,1801 E.HAZELTON:AVE.,:P.O.Bo=2009-- STOCKTON,'CA 95201 }� <br /> - ,. - �.. -Im. a -. - cc.� :. _ t.� _• ..� � _ _� Jam_/ -.r - ._ - _ g � - �i�f <br />