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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> a APPLICATION <br /> (For Non-Transferable, Revocable,`and Suspendable) SEPTAGE �. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area oft a San oaquin Local Health District <br /> N Business Name (DBA)J RE,<14 51 =KAddress 1` ��• � -� �����-- <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. - <br /> Contractor Licence No. -- <br /> LApplicants NamTitle �A1 ��� � 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) r <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. <br /> Tes L ation Test Date/Time <br /> 4. L2AANITATION PERMIT <br /> Job Address/Location <br /> Owner Address1Vf -- <br /> ❑ SEPTIC TANK ❑ SSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER �+ <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 t.1 <br /> Type Construction Disposal Site _ __— 0 <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 /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. 1 <br /> ❑ DR ' <br /> Pr fTlatfrtth"Oermanea ltlewof*forwhitfi010 grmlf1910YRd IshollriF# �a <br /> § soh 'to workm n s cora y <br /> t S1ir56 'liNitt�-#37( s+C�lt#73YSiA 574rt1 r,� �G Sun !i r.w:i r it p fty iMw <br /> 4fr ons i .4a�w is�• t3er s 'I:,: ; that is the pertgrfriartge of the wars for sY jo Iflis <br /> I hereby certify that I have re ared this applic tion and th the work bed a in accordance with Sart Joaquin County <br /> ordinances, state laws, an ru nd regulatio s f the Sa J quin al ealth i rict. <br /> APPLICANT'S SIGNATURE X <br /> a te' 3 7 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> . BILLING REMITTANCE g REMIT <br /> BASE EXPLANATION DATE T REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE T <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i <br /> Received by Date Receipt No. Permit No. Idsuante Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />