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Applications Will Be cessg en Submitted Properly Completed. Be Sure Ti n The Application. <br /> APPLICATION <br /> (For Nan-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby ma 1i0 carDTon busin sS in the' ns Ictional area of the San Joaquin L cal VHplth trict <br /> Business ame (DBA) �` ___! � Addres � -- <br /> z Owner_ Lr, h C?•fr' ` ' �� 2 .- — - Address <br /> d <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. Emergency Telephone No. - _� -- <br /> a _ <br /> Contractor Licence No. <br /> Applicants Name{Pring r Title Acu,-gL <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites - - -- <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 /> i 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> i <br /> No. of Vehicles Stored <br /> i 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 /> Job Address/Location ` <br /> O ner t5 , Address <br /> SEPTIC TANK CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT <br /> ❑ OTHER <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR — <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> iType 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 /> I <br /> SIZE: ❑ 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 fru a don in accordance with San Joaqu' ounty <br /> ordinances, state laws, an rule and regulations of the San Joaquin L cal Health Dist ct. <br /> I APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT © PER SITE ❑ EACH © January t &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DU NECKED <br /> DATE DATE REMITTED <br /> OUNT <br /> FEE <br /> LESS <br /> PRORATION — <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i Received by ate ec Permd No,.. •• Issuance D Mailed Delivered <br /> F APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERW,ES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON.CA 95201 -- <br />