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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 hereby made to carry on business in the jurisdictional area of the San Joaquin Loc4l Health District <br /> H Business Name(DBA) Lee 6t-)-a Address &S W. C14 <br /> aOwner _ lcJ 7 Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. �� Emergency Telephone No.. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title C >� f Date a �' y �� <br /> Please check Applicable Category (1-7) and Fill in the Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June 30;'19 Disposal Sites <br /> Description(Make/Yr.,Color) r <br /> Serial No. CAL. License No. CAL. License Renewal No. —L <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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No.- <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner vizSTA�i�IC r <br /> - Address <br /> SEPTIC TANK ❑ CESSPOOL i'& LEACHING FIELD IS- SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY !I@ NEW ❑ REPAIR ❑ OTHER i <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> 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 F <br /> 7. ❑ LAUNDRY 'For July 1; -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. LL <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that l hav repo thi appl' a on aril that the work+will be done in accordance with San Joaquin County <br /> ordinanc tate laws, ni U s an re ul n of t aquin Local Health District. <br /> APPLICANT'S SIGNATUR <br /> y L FOR DEPARTMENT USE ONLY => 4 - !/!/Y`/ ✓E'✓✓�.� !J <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> I REMIT <br /> AMOUNT DUE CHECKED <br /> ' BASE EXPLANATION BILLING REMITTANCE $ f <br /> -DATE- r DATE REMITTED AMOUNT <br /> FEE �7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ' <br /> OTHER <br /> / <br /> 1110,3-7 <br /> Received by Ilate IReceipt No. Permit o. '"-` Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES T .NMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 . <br />