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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 Local Health District <br /> Business Name ( BA) Address 02 Cl? S <br /> r Owner -�' Address <br /> a <br /> J Firm Partners, Addresses and Telephoa Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No.. 6 k <br /> Applicants Name (Print) > Title �'✓ — Date �" l <br /> Please check Applicable Category(1-7) and Fill in the Required Information "'NIC civet ;_a <br /> CLI,f :,:�L S [,C & S.a.-I, SERVICE <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1; Sa. Qia $iccl:i'c[1 C iii. 93tL5 4 <br /> For July 1, June 30, 19 Disposal Sites } •4,9 I - <br /> i h. 7:,.- cv moi;:;tr G�ur'S..;�.-'=2S7I77 is <br /> Description(Make/Yr., Color) <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 /> 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 /> v'9G a <br /> Job Address/,II ovation <br /> Owner Address n , <br /> -1 SEPTIC TANK 11 CESSPOOL W LEACHING FIELD SEEPAGE PIT ❑ PACKAGE 15LANT �J <br /> ❑ PERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHER <br /> 5. ❑ CHElICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. 11PACKAGETREATMENT PLANT For July 1, - June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: 0i Less Than 1,000 Sq. Ft°, ❑ More Than 1,000 Sq. Ft. ' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i <br /> ordinances, state laws, and regulations of the San oaquin L al Health District. S+ERVIeE <br /> APPLICANT'S SIGNATURE X - ,t� -_!'•-=` u':, -c 3 <br /> d <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July l &Received By July 31 <br /> t <br /> REMIT <br /> k BASE EXPLANATION BILLING - REMITTANCE $ AMOUNT DUE CHECKED <br /> 4 DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION t1 <br /> PLUS' { <br /> PENALTY ' <br /> I � � <br /> OTHER <br /> h <br /> OTHER <br /> f <br /> f O <br /> Received by a e Receipt No. rrntt NO. Issuance Date Mailed Delivered <br /> STOCKTON,CA 95241 <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.O.Box 200 - <br /> t <br />