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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication <br /> APPLICATION <br /> s (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> NTAL HEALTH PERMIT <br /> ENVIRONMENTAL <br /> OQUId WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin-Local Health District <br /> •+ yr 1r ....y..- ��wew. .,. <br /> HBusiness Name (DBA) Address Y �j <br /> a Owner _ <br /> Address. w <br /> 2 Firm Partners, Addresses and Telephone Numbers <br /> C6 <br /> Business Telephone No. Y Emergency Telephone No.� f <br /> -J Contractor Licence No. <br /> a L L Title Date ZO <br /> L Applicants Name (Print) <br /> Please check Applicable Category.(1-7) and Fill in the Required Information <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. CAL. License Renewal No. <br /> Capacity, Gal., Weights &Measures No. <br /> r <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> ForJuly1_ .__ June30;:19 , <br /> No. of Vehicles Stored <br /> I. <br /> No. of Chemical Toilets Stored ,. <br /> 3. ,❑. PERCOLATION TEST <br /> R.S. or-R.C.E. Name A.S.or R.C.E. N I <br /> Test Location Test Date/Time <br /> / <br /> 4. `❑ SANITATION PERMIT <br />. 4 � <br /> Job Address/Location r <br /> Owner /mss Address ! <br /> ❑ SEPTIC-TANK ❑ CFSSPOOL ACHING FIELD ❑� SEEPAGE PIT ❑ PACKAGE PLANT i r <br /> ❑.PERMANENT ❑ TEMPORARY ❑ NEW IeREPAIR f ❑ OTHER <br /> 5. G❑ CHEMICAL TOILETS""Fo`�July 1,-JuMe-30;T� 1 `'i <br /> Type Construction Disposal Site d <br /> No. of Units Equipment Storage/Cleaning Location(s ` <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30;99 .---� ---� <br /> Operator Name _ 1 Where Certified --. <br /> Plant Location <br /> Plant Capacity 1 "-'No.Mnits Served + <br /> 7. -❑ LAUNDRY For July 1, -June 30, 19.- - -r==3- <br /> i <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Thar) 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. _ <br /> �+� t <br /> I hereby certify that I have prepared this application and that the work will be done'in accordance'*ith San Joaquin County <br /> } ordinances, state laws, and rules and, egulations of'the San Joaquin Local Health District. <br /> � J � <br /> I- -.. <br /> APPLICANT'S SIGNATURE X 111 <br /> I Y Y I l 3 �. <br /> F ]!1 a FOR DEPARTMENT USE ONLY - t <br /> 1 <br /> }f_ Fee Is Due` ❑ ANNbALLY ❑ PER UNIT ❑ ER SITE ❑ EACH ❑!January 1 &Received By January 31, © July 1 &Received By July 31 <br /> -BILLING c`�-4.—REMITTANCE _ $ I. - REMIT <br /> BASE EXPLANATION DATE, 't ti,-"�,r,4;. DATE REMITTED- AMOUNT DUE CHECKED <br /> - - - AMOUNT ' <br /> I FEE t k'. ,'$, <br /> I [ 1 <br /> I LESS r j + <br /> � �_,may t • � �' # <br /> { PRORATION _ _ <br /> IVVt 1 ! <br /> PLUS <br /> PENALTY a i <br /> OTHER ;9ri. -A. S <br /> Received by Date Receipt No. Perrnit.No. Iss n ee Da Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES `' 1fi01 E.HAZELTON AYE.,P.O.Box 20D9 STOCKTON,CA 95201 - <br />