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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL: HEALTH PERMIT SEPTAGE <br /> lb LIQU16VA'STE <br /> Appiic Is hereby mad o carry on mess in the jurisdictionsl area oft n Joaq�uip Loc ith 13 trio <br /> FBusiness Name (DBA6 t�L>�/�/ 6� i Address /� Ir <br /> 4 Owner Address <br /> 0 Firm Partners, Address4anT hon Numbeam Business Telephone NEmergency Telephone No. <br /> Contractor Licence No. 01 <br /> L Applicants Name (Prin Title Date <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) _ f <br /> Serial No. CAL. License No. CAL. License Renewal 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. v <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PER IJ4� <br /> Job Addres ovation (p <br /> Owner Address <br /> O,'SEPTIC TANK ❑ CESSPOOL %-L�ACCHING FIELD ®'iMPAGE PIT ❑ PACKAGE PLANT �`. IC F <br /> ❑ PERMANENT ❑ TEMPORARY ZHIEW ❑ REPAIR ❑ OTHER 1' <br /> 5. ❑ CHEMICAL_TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units -Equipment Storage/Cleaning Location($) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified N <br /> Plant Location' --- <br /> Plant Capacity _ No. Units Served <br /> 7. 11 LAUNDRY-_­ <br /> >=or July 1, -June 30, 19 <br /> SIZE: El Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ; <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have pr d this applicati d that the�or <br /> will be done in accordance with San Joaquin County <br /> ordinances, state laws, an and r latio qI Health District. <br /> w <br /> APPLICANT'S ATURE X <br /> r <br /> Gef/�'s e <br /> FOR Q� fill"" <br /> ok <br /> DEP' TIME T U�fnuar�_y <br /> Y <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EACH •&Receiveq By January 31 ❑.July 1 S Received By July 31 <br /> - REMIT <br /> BILLING E ANCE $ <br /> BASE <br /> EXPLANATION DA D E REMITTED AMOUNT DUE '"CHECKED <br /> - R- -� AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date ceipt No, Permit No. y- lssu5nce Date Mailed Delivered / 3 fd <br /> APPLICANT—RETURN ALL COPIES TO: EN IRONMENTAL HEALTH PERMIT/SERVICES - 1501 E.HAZELTON AVE.,P.O.Box 20119 STOCKTON,CA 95 d <br />