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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> *1 (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> -ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE {��-{Q - GO-!( <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name (DBA) P,R P-0-1-VM j-/ so.r s _ Address Pe .Box /yso Sre�c-/�y-e.d 9S_-o� <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. G�—96d 7 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) firma to Title �' R �� Date y� <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) <br /> Serial No. CAL. License No. CAL. License Renewal No. f <br /> C Capacity Gal.,Weights & Measures No. <br /> -Equipment Parking Address <br /> �2. ❑ PUMPER YARD <br /> iFor July 1, June 30, 19 - <br /> No, of Vehicles Stored J <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. 3 <br /> Test Location Test Date/Time <br /> Z <br /> 4. Z SANITATION PERMIT AJ.W, <br /> Job Address/Locatio �R � tv� Q 'u T nl <br /> Owner A2 ' G1 d Add ress � � <br /> SEPTIC TANK Il CESSPOOL 9 LEACHING FIELD ® SEEPAGE PIT 11 PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY 04 NEW 1:1REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site Q <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name '� t 'P10. Where Certified ° <br /> 1 <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 i <br /> SIZE: ❑ 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 that the work will be d_ne in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of San Joaquin Local Health Di ct. <br /> APPLICANT'S SIGNATU X <br /> FOR DEPART NT USE ONLY <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT <br /> El SITE ❑ EACH January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REWTTED AMOUNT <br /> F <br /> FEE <br /> t LESS <br /> PRORATION <br /> PLUS ` <br /> PENALTY <br /> �-OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> 1. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> 1 <br />