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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 /> SEPTAGE <br /> ENVIRONMENTAL HEALTH,PERMIT <br /> LIQUID WASTE <br /> Application is he y made to c rry gn business in the jurisdictional area of the San Joaquin Local Health Di ri t <br /> w Business Name (DBA) Address O 4N 113 }.,i <br /> z Owner Address <br /> Firm Partners, Addressesan Telephone Numbers <br /> I Business Telephone No. "�(of5"� Emergency Telephone No, <br /> A Contractor Licence No. ~ <br /> L Applicants Name(Print) ` 4J Title. Date <br /> �� �, : E 3 <br /> pp Category 7} Required Information <br /> Please check Applicable Cate 4 (1.7 and Fill-in the Requ , <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,.._. June 30,.19 ---- -._ Disposal Sites. — <br /> Description(Make/Yr., Color) <br /> Serial No. __CAL. License No. r CAL. License Renewal No. <br /> Capacity Gal.,Weights & M asures 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.=: t <br /> t: <br /> 3. ❑ PERCOLATIO`N TEST F. #- ` •. . <br /> R.S. or R,C-:E. Name' ! _ R.S. or R.C.E. No. I <br /> � U <br /> Test L catiprl� Test Date/Time <br /> 4/ SANITATION PERMIT <br /> Job Address Ocation C) A L <br /> Owner Address ' s <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAC�PL <br /> PERMANENT ❑ TEMPORARY 11NEW WREPAIR OTHER L.ACL-' <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ' A <br /> Type Construction _ Disposal Site <br /> No. of Units "Equipment Storage'/Cleaning Location(s)0-_17`1-,. <br /> 6. ❑ PACKAGE TREATMENT PLANT'For July 1, -June 30, 19- _ <br /> r <br /> r ,= "Where Cer[ified, <br /> Operator Name t <br /> Plant Location Of - <br /> 'Plant Capacity No Untts Served <br /> 7. ❑ LAUNDRY For.July 1, -June 30, 19 <br /> d' r <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,' ❑ More Than 1,000 Sq..Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t <br /> i <br /> s <br /> hereby certify thatel have prepared this ap ation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and a n of San Joaquin Local Health District. <br /> IZZ <br /> APPLICANT'S SIGNATURE X i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Jdnuary 31 ElJuly 1 &Received By July 31 <br /> REMIT' <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED a,AMOUNT <br /> FEE <br /> LESS f <br /> PRORATION <br /> PLUS + + <br /> PENALTY. _ r .xr .!/ <br /> J. <br /> OTHER <br /> ... <br /> —OTHER.:. �•'-- -..tial-r...,�..... � w r..,. .,�.... � a,.. .+., .�.: ...._ <br /> � n - <br /> Received by Date- d ` .01 Receipt No. .as 1 �Br111it No-� ���,;,�•� Issuance Date ,Mailed r�-:-""-Delivered <br /> APPLICANT—RETURN ALL COPIES TO:_ "ENVIRONMENTAL HEALTH PERMIT/SERVICES, '1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201' <br />