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Applications Will Be Processed When Submitted Properly o <br /> APPLICATION j <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> rY ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> ��d�srp c,�• gs�ss <br /> gppl kation is hereby made to carryon business in the jurisdictional area of th�Q Joaquin Local Health District <br /> An-Than <br /> 5 o N Address <br /> rn Business Name (DBA) Address <br /> a Owner <br /> u Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> —z 3-y � <br /> aBusiness Telephone No. !"' sR4 <br /> _J Contractor Licence No. Title Go<y7� .OcTo r Date <br /> L Applicants Name(Print) <br /> ti�� fJ�ThoK <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH es VEHICLE) <br /> For July 1, June 30, 19 Disposal <br /> CAL. License Renewal No. <br /> Description(Make/Yr.,Color) f CAL License No. <br /> i Serial No. <br /> I 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 R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> q, C3 SANITATION PERMIT/ 5 8 /r u� h Rd w � <br /> Job Address/Location Address .y,/ i o Owner 13 PACKAGE PLANT <br /> f�' <br /> SEPTIC TANK 11 CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT C1 NEW ® REPAIR C3 C1 <br /> 4 ❑ PERMANENT 11TEMPORARY <br /> j 5. ❑ CHEMICAL TOILETS For July 1, June 30, 1pisposal Site <br /> y <br /> Type Construction <br /> I Equipment Storage/Cleaning Location(s) <br /> No. of Units <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> i Plant Location No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1,-June 30. 19 <br /> Than 1,000 Sq. Ft. <br /> ` SIZE'. 13 Less Than 1,000 Sq. Ft., \ <br /> j <br /> 11 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> lication and that the work will be done in accord ce Ith San Joa In ounty <br /> I hereby certify that I have prepared this app <br /> tions of the San Joaquin Local Health District <br /> ordinances, state laws, and rule and regula : <br /> t <br /> r; APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> ❑ January 1 &Received By January-3t ❑ July 1 &Received 3y July 31 <br /> f - .❑ PER SITE ❑_ EACH REMIT <br /> L Fee is Due, ❑ ANNUALLY ❑ PER UNIT $ AMOUNT DUE CHECKED <br /> _ BILLING REMITTANCE REMITTED AMOUNT <br /> . BASE - EXPLANATION DATE DATE <br /> I <br /> FEE <br /> LESS <br /> PRORATION <br /> r <br /> PLUS <br /> PENALTY <br /> k <br /> OTHER <br /> F <br /> I OTHER <br /> Rec <br /> Issuance Date Mailed Delivered <br /> Permit No. STOCKTON, 01 <br /> Received by Date eipt No. - 1601 E.HA2ELTON AVE.,P.O.Box 2009 CA 952 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITl5ERVIGES <br />