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Applications Will Be Processed When Submitted PropertyCompletea. esesure lw�w •� -rr <br /> APPLICATION <br /> ,(For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTS HEI�I_TH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Address <br /> N Business Name <br /> DBA) Z d c <br /> i <br /> r Address <br /> Owner <br /> It <br />°.Firm Partners, Addresses and Telephone Numbers"/I- Emergency Telephone No. <br /> a Business Telephone No. <br /> f <br /> Contractor Licence No. �y tt/n Ir Date y 7 <br /> Title <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7)and Fill <br /> In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(MakeNr., Calor) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Gal.,Weights &Measures No. <br /> Capacity <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 ocabon <br /> 4. SANITATION PERMIT o+n <br /> Job Address/Lotion <br /> e <br /> err Address <br />, Owner ❑ PACKAGE PLANT <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT 4 <br /> ❑ TEMPORARY ❑ NEW E] REPAIR ❑ OTHER <br /> 'PERMANENT 4� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction <br /> Disposal Site = <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br />} Operator Name <br /> fl Plant Location No, Units Served <br /> Plant Capacity <br /> 7. C3LAUNDRY For July 1, -June 30, 19 <br /> O <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 done in accordance with San Joaquin County <br /> ordinances, state law/s,,, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> ' PER UNIT ❑ PER'SITE F-1EACH ❑ January.1 &Received By January 31 July 1 8 Received By July 31 <br /> Due: ❑ ANNUALLY ❑ REMIT <br /> Fee Is <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> F. BASE EXPLANATION ATE D TE REMITTED AMOUNT <br /> f r ay7 � <br /> FEE J s J <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Dale Receipt No. Permit No. <br /> Issuance Date Mailed Delivered <br /> Received by - 1601 E.HAZELTON AVE..P.O.Sox 2094 STOCKTON,CA 95201 <br /> I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVIGE <br />