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-Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ' (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> + LIQUID WASTE <br /> Applic4isby made to arryon busine sin the juri dicnal area of the San aquin Local Health DistricBusiness Name } Address �mz OwnerdressFirm Partners, Addresephone Num ers <br /> aBusiness Telephone No. Sr IT-f0Emergency Telephone No, <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date r 1 <br /> 14 <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> I 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. <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, _. ' r °• <br /> No. of-,Chemical Toilets Stored I <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name ti R.S.or R.C.E. No. <br /> Test, cation• Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/ cation . T <br /> Owner Address - <br /> ❑ SEPTIC TANKf ❑ CESSPOOL EACHING FIELD W S EPAGE pIT""Q-PACKAGE-PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 11NEW REPAIR ❑ OTHER <br /> 5., ❑ CHEMICAL TOILETS For July 1, -June 30119 t J <br /> I <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 i <br /> 0perator,Namel)9 Where Certified <br /> Plant Location _ y <br /> Plant Capacity No. Units Serveds�- <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <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 and102;the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule egulati ns of the n aq Local Health District. <br /> APPLICANT'S SIGNATURE <br /> FOR DEPARTMENT USE ONLY <br /> t <br /> FeeIS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑'EACH ❑ January 1 &Received By January 37 El July 1 &Received By July 31^ <br /> REMIT <br /> l•�• BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE .CHECKED , <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS i <br /> PENALTY <br /> r OTHER <br /> OTHER <br /> Received by Date Receipt No. - Permit No Issuance Date Ma'ed Delivered <br /> aAPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 .STOCKTON,CA 95201 <br />