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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> a (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> a ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on buesus In hhee jurisdictional area of the Sa .JTquin Lgcal Health Distrip <br /> rn Business Name (DBA)k Address :3 L -_- <br /> aowner. .� Address I—S k-:?� <br /> J Firm Partners, Addresses and,T le hong Numbers <br /> a ` <br /> Business Telephone No.� ��� _ Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Nan C_k L--- Title ct5i k (` Q_-.Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information w <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 7 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <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 /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Add r s/Location <br /> Owner YAG- A\\cWress;� _ <br /> SEPTIC TANK 11 CESSPOOL LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT .) <br /> PERMANENT ❑ TEMPORARY &I NEW ❑ REPAIR ❑ OTHER .-1 <br /> 5. ❑ CHEMICAL TOILETS For July 1, - une 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 /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: 11 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 prepared this application and.hat the work will be done in accordance with San Joaquin Coui my <br /> ordinances, state laws, les a d r R, Ral Health District. +" <br /> APPLICANT'S SIGNATU - <br /> a <br /> 1 _ , <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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FEEAll <br /> LESS <br /> PRORATION <br /> PLUS _ <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 i <br /> } <br />