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Application's Will Be Processed When Submitted Properly Completed. Be_ Sure To Sign The Application. <br /> . . .¢ APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) f( SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> LIQUID WASTE <br /> i Appl icati n is hereby made tQ c_ar on busin in the' rl dlctional area of the S_ Joaquin Local Health District t <br /> m Business Name {DBA} � � - Address G .L✓�� r ` � , ca <br /> a Owner LE F. � L �. _ <br /> �.[,�� , Address _ <br /> J,Firm Partners, Addresses a el�i hone Numb rs __ { <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor L'icence•No. _ <br /> Apiplicants Name(Pr t) C C � - Title �--� -Date <br /> Please check Applicable Categoryk(1-7) and Fill in the Required Information z , x L } <br /> 1. ❑- PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19- �� Disposal Sites- 1 <br /> Description(Make/Yr., Color) .q <br /> Serial No. I CAL. License No. CAL License Renewal No. <br /> 'CapacityGal.- <br /> Weights'&"Measures-NO.— <br /> Equipment <br /> NO.—E ui ment Parking Address <br /> TI <br /> - <br /> 2. ❑ PUMPER YARD <br /> `For July <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> 'R.S. or R.C.E. Name N R.S. or R.C.E. No. <br /> !Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address7Loc2tionct <br /> Owner U� ` Z Z)i R -N E i T Address <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT = <br /> ❑ PERMANENT ❑ TEMPOR"ARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For'July 1, -June 30, 19 r '"'- T <br /> Type Construction 4 Disposal Site - <br /> TNo, of Units M Equipment Storage/Cleaning Location(s) i ! <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 f �' <br /> . Operator Name Where Certified--- --t1 <br /> -Plant Location r <br /> Plarit Capacity �� Y No. Units Served. r <br /> i <br /> 7. ,❑ LAUNDRY For'July 1, -June 30, 19- " a { <br /> SIZE: . ❑'Less Than 1,000 Sq: Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify 7tht have prepared this application and at the work will be done in accordance with San Joaquin County ' <br /> ordinances, sta lavys, a d ri tes an regulatAns the S J.oa in Local Health District. <br /> 'APPLICANT'S SIGNATURE X / <br /> FOR DEPARTMENT USE ONLY .... <br /> Fee Is Due: 11ANNUALLY ,I ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Fleceived By January 31 ❑ July 1 &Received By July'31 c w 1 <br /> ' REMIT <br /> r <br /> BASE I EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKEp' <br /> ,.�'} r' s DATE ATE t REMITTED AMOUNT <br /> FEE ✓� <br /> t i . <br /> 3 LESS <br /> PRORATION <br /> PLUS <br /> PENALTY L I S ? <br /> ! OTHER <br /> I OTHER .> Ili V AAF <br /> x <br /> Received by _ Date Receipt No 'k Permit No. '-Issuance Date ailed Delivered. - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />