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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) ` <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicatiois here y made to carryon busi ess,in the jurisdictional area of the n/J�oaquin Local Health District <br /> ,F Business�iame (DBA) S <br /> Address—..- a3 S'r, 7 Grp/ <br /> aOwner �, .16,14r .3' Address C _4"" <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. � Emergency Telephone No. <br /> Contractor Licence No. "f <br /> LApplicants Name Title Date <br /> e <br /> Please check Applicable Category (1-7) and Fill in the Required Information Ci nEft j 'S $cI'r:'0 2, SEWER SERVIC} I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 2i.=3 So. Uro ,.s �tockton Calif. 95205 <br /> For July 1, June 30, 19 Disposal Sites Ph 4ua. <br /> Description(Make/Yr., Color) cx�) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. x <br /> Equipment Parking Address t�f <br /> I 2. ❑ PUMPER YARD @� <br /> For July 1, June 30, 19 �y <br /> No. of Vehicles Stored 7 <br /> No. of Chemical Toilets Storedt <br /> 3. ❑ PERCOLATION TEST [ <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Test Location Test Date/Time i <br /> 4. ❑ SANITATION PERMIT / •�/ / ,,/ <br /> Job Address/Lo tioD � <br /> Owner f/_ Z Address,� e e c ti <br /> SEPTIC TANK El CESSPOOL LEACHING FIELD �e0 SEEPAGE PIT ❑ PACKAGE PLANT JI <br /> PERMANENT ❑ TEMPORARY 0 NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 t <br /> r Type Construction Disposal Site t <br /> i No. of Units Equipment Storage/Cleaning Location(s) <br /> I 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 4 <br /> F <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 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 application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rul and regulations of the San Joa in Local Health District. i <br /> APPLICANT'S SIGNATUREX r =:I L1+lCE'S SrYT;C <br /> . 26 `:r:. 65203 <br /> ice <br /> nE 7,.tC, ' 17 A <br /> h <br /> FOR DEPARTMENT USE ONLY ---- <br /> Fee IS Due: ❑ ANNUALLY x❑ PER UNIT._. 11 PER SITE s❑ EACH ❑ January 1 &Received By January 31 + ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE t <br /> LESS <br /> PRORATION J �( <br /> PLUS <br /> PENALTY <br /> 1 <br /> OTHER <br /> 1 <br /> OTHER <br /> CJ <br /> rte\ � ����f � <br /> Received by Date Receipt NO. Permit No. Issuance 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 />