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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. 't <br /> �0 APPLICATION . <br /> (For Non-Transferable, Revocable,and Suspendable) F <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> Al <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of th an Joaquin Local Health District <br /> H Business Name (DBA)D� L�s � Z <br /> � r- ' Address <br /> 4 Owner Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> ad7 Emergency Telephone No. <br /> CL Business Telephone No. — <br /> Contractor Licence No. <br /> L Applicants Name (Print) ST �a S/,eo, Title 7dr-Z,- Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information 4 , <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) t <br /> Serial No. CAL. License No. CAL. License Renewal No. <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 /> r r., <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 Addl*ss/Location Z40ex, Ad' <br /> Owner/ /� � I Address dL�V C'r Z-0 AD <br /> Rr�EPTIC TANK ❑ CESSPOOL BLEACHING FIELD 2JEEPAGE PIT ❑ PACKAGE PLANT <br /> [?'PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <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. 11 PACKAGE TREATMENT PLANT For July 1, -June 30­19 t <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served. <br /> 7. ❑ LAUNDRY For July 1, -Jun 30, 19 a ` <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 SqFt. `• "4 �' <br /> t <br /> ❑.,DRY CLEANING, Chemicals,Used/Amount/Mo. <br /> I hereby certify that I hav prepared this application an that the work will be done in accordance with San Joaquin County h <br /> ordinances, state laws, ales an gulation the anAaquin Local Health D tri t: ,. -t <br /> ��7 a <br /> APPLICANT'S SIGNATURE <br />'I r it <br /> r � <br /> FOR DEPARTMENT US 3' <br />` x <br /> k f <br /> Fee IS Due- ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE <br /> El ❑ Ja 1 &Received By January 31 ❑.July 1 &Received By July 31 <br /> REMIT <br /> EASE EXPLANATION BILLING RElr�l TTA CE�� $ AMOUNT DUE CHECKED <br /> DATE ATE REMITTED [r AMOUNT <br /> r <br /> • 'FEE <br /> LESS *_ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> tR� D�� <br /> Received by Date Receipt No. Permit No. issuance Date ailed Del7vered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 'STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />