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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 reby made to car on busine in the.ur d icti nal area of the oaqu'nLocal Heal District <br /> rBusiness Name (D } Address #' 6 <br /> aOwner dress _. 4 <br /> L) Firm Partners, Addresses and Telephone Numbers �- <br /> aBusiness Telephone No. –151/tyEmergency Telephone No, <br /> Contractor Licence No. —7- <br /> Applicants Name (Print) Title Date <br /> Please check Applice ble-Category (1=7)and Fill in the Required Inform tion <br /> , <br /> 1. ❑ PUMPER VEHICLE.PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For r Jul ,.. <br /> y 1, '� June 30,-.19 Disposal Sites <br /> EDescription(Maker/,Y�r.-rCoIolor) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity . 1. Gal.,Weights & Measures No. <br /> Equiprr eht Parking`Add ss .. – <br /> 2. ❑1PUNIPER YARD <br /> For 'uly 1, June 30!19 � <br /> No:of Vehicies Stored 16 <br /> No of Chemical Toilets Stored! ► s s'.y <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. _.1 <br /> Test Lo ion Test Date/Time * <br /> 4. 2SANITATION PERMIT i N r <br /> Job Addressl oca ion tf <br /> O��wn��er Address <br /> 'SEPTIC TA ❑ CESSPOOL W<EACHING FIELD CA�S�EEPAGE PIT ❑ PACKAGE PLAN OC} <br /> ❑ PERMANENT ❑ TEMPORARY 11NEW L�REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 A �+ <br /> OrA; .:. . <br /> Type Construction Disposal Site _ <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> S. © PACKAGE TREATMENT PLANT For July 1, -June 30-19 <br /> Operator Name 10 'T' Where Certified I <br /> Plant Location I <br /> Plant Capacity I No. Units Served 9 1 <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ) >R <br /> SIZE: <br /> El Than 1,000 Sq. Ft., ❑ More Than 1,000+r5q. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. it i <br /> �" + <br /> I hereby certify that I have prepared this applicationand that the work will-tie=done in accordance with San Joaquin County 4 <br /> ordinances, state laws, and rules regulations of thtFtBn J Lin Local Health District. <br /> APPLICANT'S SIGNATURE X - t <br /> L,� - <br /> �1 <br /> FOR DEPARTMENT USE ONLY � <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received KRy Jan1 ry 3) ❑ July 1 &Received By July 31 , <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCEAMOUNT DUE CHECKED <br /> DATE DATE REM$ AMOUNT <br /> 3 <br /> FEE <br /> LESS 1 + a,: x:?►„ ,,,rx <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r r <br /> Received by - Date Receipt No. - Permit No. I suance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />