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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> Non-Transferable, Revocable,and Suspendable) j <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> �-^-� Application is hePe made car on busi sin t e j " dictional area of the Sa �quin al Health District <br /> w Busine a (DBA) y[ Address y Q r <br /> 1 <br /> aOwner Address 2 4jd • /4do'- .+' . <br /> 1Firm Partners, Addresses and Telephone Numbers z / <br /> ► a Business Telephone No. 3X . �-. ��,4 Emergency Telephone No. f�/ <br /> Contractor Licence No. o ,Y <br /> L Applicants Name (Print) '54Q-A, c 7�&_E+ . Title Date <br /> Tease check Applicable Category (1-7)and Fill in the Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, _ June 30, 19 Disposal Sites �a <br /> Description(Make/Yr., Color) <br /> Serial No. - CAL ense No. Y GAL. Liccnse Renewal No <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address r, <br /> 2. ❑ PUMPER YARD <br />; For July 1, June 30, 19 <br /> f' No. of Vehicles Stored _ <br /> j No. of Chemical Toilets Stored <br /> II 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,6,=r7 f <br /> Jot? Address/ oc tion N <br /> Owner Addres,10, 9="'52 <br /> tl�'�EPTIC TANK -1 CESS LEAGHiNG FIELD L�'�EEPAGE PIT ❑ PACKAGE PLANT Qlz <br /> E' <br /> PERMANENT ❑ TEMPORARY 13—NEW ❑ REPAIR ❑ OTHER >J <br /> j 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. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No..Units"Served ' <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 _ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. `y <br /> „ O <br /> 3 <br /> I hereby certify that I have prepared,this appli ion.and that the work will be done in accordance with San,Joaquin County <br /> ordinances, state laws, and rules regulati o he an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑.ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> REMIT <br /> - - BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE. CHECKED . <br /> f DATE DATE REMITTED MOUNT ! ' <br /> t <br /> FEE - <br /> LESS <br /> PRORATION /J <br /> PLUS <br /> - PENALTY �•�, <br /> - - OTHER <br /> �f <br /> {� OTHER <br /> QLI <br /> Received by Date k Receipt No. Permit No. Is!tuancib Date Mailed Del' ere <br /> -r APPLICANT—RETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PEAMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Box 2009 -STOCKTON,CA 96201 <br /> J <br />