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Applications Will Be Processed When Submitted ProperlyCompletestie sure Ivo191, r�nrr••w- <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable)' SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT r <br /> LIQUID WASTE <br /> Applicatlon is hereby made to carry_ n business in the jurisdictional area oft San aquin Local Health District 9 �I <br /> Business Name (DBA)1:>A_ �"-- 1 �b � � — Addresses• <br /> z Owner, Address <br /> 4 <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. — Emergency Telephone No. <br /> a � <br /> Contractor Licence No. Date <br /> L Applicants Name (Print) t Title <br /> Please check Applicable Category (1-�a, illin She Required information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(MakelYr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License 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. S"SANITATION PERMIT <br /> Job Address/Location [. I 11Ft3 t 7V• ` <br /> Owner�a� { Address <br /> �r <br /> SEPTIC YANK L3CESSPOOL LEACHING FIELD W SREEEPAAR ❑OTHER E PIT- fl'a(?ACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY XNEW <br /> 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 /> 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: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> t <br /> hereby certify that L hav prepared this application that the`v4+ will be done in accordance with San Joaquin County <br /> ordinances, state laws, r les and reg tions of a an J q ' L ca ealth District. t <br /> 4 ' <br /> APPLICANT'S SIGNATURE <br /> f=OR DEPARTMENT USE ONLY y , <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE- 0 EACH w 0 January 1 Recei v d.By January 31 ❑ Ju4y 1 &Received By July 31 <br /> REMIT <br /> • s BILLING REMITTANCE -'$ 7AIMOUNTUE CHECKEDBASE �' EXPLANATION°' DATE- c DATE,( REMITTED AMOUNTdoFEE ` <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date 'Receipt No. Permit NO. ssua c ate Mailed Delivered <br /> 1601 E.HAZELT P.O.Box 20x9 STOCKTON,CA 55201 <br /> APPLICANT—RETURN ALL COPIES TO:, ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />