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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> -�_ APPLICATION <br /> " (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of-the Sa L L c I He I h D' t <br /> ,r-Business Name (DBA) 11r DO-riald SePtiC Service. Address ��+ 1�C�lre 1 Lade <br /> z Owner ld Address same <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. Emergency Tele o <br /> PU <br /> Contractor Licence No. <br /> Applicants Name(Print) t (�� r Title `J�1Date j <br /> Please check Applicable Category (1-7)and Fill In the Required Information r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) vJ I <br /> For July 1, June 30, 19 Disposal-Sites j 0 <br /> Description(Make/Yr:, Color) '1 ear- - ' - "*�. � r <br /> Serial No'' w CAL. License No. CAL. License Renewal No.-- <br /> Capacity Gal.,Weights & Measures No. f <br /> Equipment Parking Address µ <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 _ i...\ illi R.S. or R.C.E. No. <br /> Test Location <br /> I * Test Date/Time ab <br /> 4. ❑ SANITATION PERMIT r.. x' '�' •' <br /> Job Address/Location I �" " '' ' r. <br /> Owner <br /> SEPTIC TANK ,CESSPOOL LEACHING FIELD © EEPAGE PIT ❑<PACKAGE PLANT j <br /> PERMANENT ❑ TEMPORARY PrNEW ❑ REPAIR ❑ OTHER ,ID <br /> 5. ❑ CHEMICAL TOILETS'4For July 1, -June 30, 19 � <br /> Type Construction t Disposal Site -•i"f <br /> No. of Units •. Equipment Storage/Cleaning Location(s) I <br /> f 6. ❑ PACKAGE TREATMENT PLANT—For.July,1, -June 30, 19 <br />_R Operator Name r Where Certifieri s <br /> Plant Location } <br /> Plant Capacity iii No. Units Served ) g <br /> 7. ❑ LAUNDRY For July'1, ,June 30, 19 <br />' ! SIZE: ❑ Less Than 1,0003q. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - �, - - <br /> I hereby certify that I have prepared this application and that the work will be done+in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulati of the San Joaqu' Local Health District. i <br /> i <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY *r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT [I PER SITE ❑ EACH ❑ Jan ry 1 ived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING RE TTA $ I <br /> r BASE EXPLANATION AMOUNT DUE CHECKED <br />- DATE AT REMITTED AMOUNT i <br /> FEE Ll kit, <br /> s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 7 <br /> " <br /> OTHER f <br /> o <br /> Received by Date Receipt No. Permit No, I55 ant�D? <br /> Malled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />