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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> S„ (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 of the San juin L, al Health strfc l� <br /> r„ Business Name (DBA) 71 6 C,n •\, Address j �T� ` / �.✓�• <br /> i Owner�����,e �� P.. Address <br /> a <br /> 1 Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 02 -16 <br /> L Applicants Name (Print) I Title 19921r =� 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) <br /> Serial No. q CAL. License No. CAL. License Renewal No. <br /> Capacity ..Gala Weights 8 Measures_.No_ <br /> Equipment P,arkiflg Address <br /> t <br /> 2. ❑ PUMPER-YARD, iJ <br /> For July 1, Jbne 30, 19 { <br /> No. of Vehicles3to[ed <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST rr <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 Address/Location 00 y� ��C�<�C��, ��� .�UC /17T�'� <br /> O_,wn � Address 6i��L� <br /> UrSEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑l SEE AGE PIT 13 PACKAGE PLANT E _ <br /> ❑ PERMANENT ❑ TEMPORARY El NEW W O AIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 G, <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 ,l Where Certified I <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 -4 — ti <br /> SIZE:-, % ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000ASq. Ftd # <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. (� <br /> it hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin.County <br /> ordinances,_state laws, and rules and regul ns o)j_Lhe San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FO DEPARTMENT U$EIONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PEFi UNIT Q.PER.5ITE 13 EACH ❑iJarfuary 1 &Received By`January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> i BILLING- IT REMANCE--i 3 <br /> BASE EXPLANATION # DATE DACE i REMITTEAE AMOUNT DUE ' AM UND <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> -PENALT4i(-- <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuan a Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95261 ^ <br />