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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION , <br /> r(For Non-Transt'eraible;-Re"cable,and Suspendable) <br /> _ <br /> ENVIRONMENTAL HEALTH'PERMIT SEPTAGE <br /> LIQUID WASTE <br /> AppFica ion is hereby made to rr� n mess in t e j risdic1,onal area of#h an oa uin Loca�eallhDi \\ <br /> rBusiness Name (DBA) <br /> aOwner .� Address . <br /> Address <br /> 1 Firm Partners, Addresses and le ne Cumbers - <br /> aBusiness Telephone No. <br /> Contractor Licence'No: <br /> Emergency Telephone No.. <br /> L Applicants Name (Pririt) <br /> Title ate <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1.' ElPUMPER 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. _ LL <br /> CAL. License Renewal No. <br /> Capacity-_- —' Gal' Weights $ Measures'No:-­4 "A— <br /> Equipment Parking Address'_ — — <br /> 2. ❑ PUMPER YARD <br /> 'ForJuly'1;- --- June-30,-19-----=T- — --- _. <br /> No. of Vehicles Stored --- -- - <br /> No. of Chemical Toilets Stored �. <br /> 3. ❑ PERCOLATION TEST <br /> R.S.br R.C.E. Name �`^ - ' t <br /> R.S. or R.C.E. N6k, ^ ,V <br /> TestlLocation Test Date/Time <br /> 4. SANITATION PE T ``-y <br /> Job Ad ss/Location <br /> E Owner <br /> Addres' ' f <br /> SEPTIC TANK CESSPOO' EACHING F ❑ <br /> ELD L '7 <br /> PERMANENT ❑ TEMPORARYEyN 9,SEEPAGE PIT PACKAGE PLANT 7, <br /> 5. 11 CHEMICAL TOILETS For July 1, -ljn�� <br /> e 30, 19 ~ ❑ REPAICR,, ❑ OTHER <br /> Type Construction DisposalSito Y, _ M; """"'��`��r' ""e—$ �►. <br /> No. of UnitsY Equipment_StorageZCieariing Locatjon(s), <br /> i 6. El PACKAGE TREATMENT PLANT For July;J.,'-June 30, 19 r i <br /> i <br /> Operator Name Where Certified ti <br /> Plant Location i_ 0 , <br /> Plant Capacity F� _1 �4 r No. Units Served G <br /> 7. ❑ LAUNDRY For July 1,•-June-30 19 'z <br /> SIZE: ❑ Less Than 1\000 Sq, Ft., r , <br /> ❑ More Than 1,000 Sq. Ft. c ( <br /> ❑ DRY CLEANING, Chemicals.Used/AmOUnVMO. - <br /> 9V t <br /> herebycerfi 'his <br /> fy-that I have prepared' <br /> repared' ap lication nd that the work will be done in accordance with San Joaquin Cou <br /> ordinances, s e laws, d rules and Y ula a Sari J qu' ocal Health District. nty <br /> APPLICANT'S SIGNATURE X e <br /> FOR DEPARTMENT USE ONLY ` <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE + ❑ EACH - <br /> . _ January 1 &Rleceived By January 31 ❑ July 1 &Received By July_31 <br /> BASE EXPLANATION BILLING REMITTANCE _ $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED ; <br /> FEE S% 'V( AMOUNT <br /> LESS - <br /> 1 PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> a OTHER r ' <br /> PI+ <br /> Received,by Date _ . -.. .� ,.- <br /> - Receipt No', e F 1 Permit No.+ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES '`j 1<•. Issuance D Mailed _ Delivered - <br /> 1601 E.HAZELTO .,P.O.Box 20D9 STOCKTON,CA 95201' <br /> ' E F 1 <br />