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flcations Wfi1 Be Processed When Submitted ProperlycomPlere�. <br /> -` - APP APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT 4 <br /> 4 LIQU.10 WASTE A, <br /> •+ Applicatio is ereb made to car on business in the urisdictional area oft San Joa uin Local Health DistricIII t <br /> r <br /> �h Address <br /> rn Business Name (DBA) Address <br /> z Owner i, <br /> I <br /> 9 Firm Partners, Addresses and Tele hone Numbers Emergency Telephone No. <br /> aBusiness Telephone No. <br /> Contractor Licence No. Titles— Date <br /> .p <br /> fApplicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> r 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> June 30, 19 <br /> I For July 1, Disposal SitesI� <br /> Description(Make/Yr., Color) CAL. License No. CAL. License Renewal No. <br /> Serial No. I, <br /> Gal.,Weights & Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> I� <br /> 2. ❑ PUMPER YARD s.,•r <br /> For July 1, June 30. 191- 0 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored I� I <br /> i 3. ❑ PERCOLATION TEST R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name ` <br /> ilk Test Date/Time <br /> Test Location <br /> 4SANITATION PEIRIII 17 ,�` #- r /' <br /> Job Addr s/ ocat, I� r r Address <br /> I Owner ❑ PACKAGE PLANT 1 <br /> l JE SEPTIC TANK llCESSPOOLI� LEACHING FIELD SEEPAGE PIT ❑ OTHER I <br /> PERMANENT <br /> ❑ TEMPORARY M NEW ❑ REPAIR I <br /> 5, ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> :11' Disposal Site <br /> Type Construction <br /> IlM' Equipment Storage/Cleaning Location(s) <br /> No. of Units <br /> �.: <br /> g, 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> 'IMS <br /> Operator Name I� <br /> Plant Location I� No. Units Served <br /> Plant Capacity - <br /> 7. ❑ LAUNDRY For July 1M`-June 30, 19 <br /> SIZE: ❑ Less Than 1,000;5q. Ft., C3 More Than 1,000 5q. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mi <br /> F <br /> r <br /> San County <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with <br /> ordinances, state laws, and rules and regulatio s of the San Joaquin Local Health District. ; <br /> APPLICANT'S SIGNATURE X <br /> I I FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUA LY ❑ <br /> PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT <br /> uIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> :BASE EXPLANATION DATE DATE REMIITT AMOUNT <br /> O <br /> FEE 5 <br /> LESS IIIA <br /> PRORATION IIIA <br /> f <br /> PLUS II� <br /> PENALTY <br /> OTHER III <br /> OTHER il� <br /> ' b"7 ��./1 1p �. <br /> I �- {ssuanca Date ailed elivered I f <br /> �Y Date Receipt Ni Permit No. <br /> Received by R � 1fi01 E.HAZELTON AVE.,P.O:BOX2009STOCKTON,GA 9 01 <br /> E - APPLICANT—gETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES — _ - <br />