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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 /> Application is hereby made to carry on business in the jurisdictional area of the, n Joaquin Local Health District r � <br /> y Business Name (DBA) <br /> aOwner Address <br /> J Firm Partners, Addresses a,,1d elephone Numbers <br /> a. Business.,Telephone No. � t Emergency Telephone No. <br /> a <br /> Contractor Licence No. - . .. _ :.t • <br />-. L Applicants Name (Print) i Title ate <br /> Please check Applicable Category (1-7)and-Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) ""' -y' <br /> Serial No. 'CAL. License No. CAL. License Renewal No. <br /> Capacity - Gal.,'Weights &Measures No. <br /> :Equipment Parking Address - -- {- <br /> 2.. ❑ PUMPER YARD <br /> For July 1, June 30, 19 t <br /> .No. of Vehicles Stored <br /> No`of Chemical Toilets Stored <br /> 3. 0 PERCOLATION TEST r <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time # I <br /> 4. ❑ SANITATION PERMIT_ <br /> Job Address/Location <br /> Ow5� <br /> `nerAddress• `� <br /> SEPTIC WANK ❑ CESSPOOL LEACHING FIELDS SEEPAGE PIT *'❑'PACKAGE•PLANT' <br /> ❑ PERMANENT ❑ TEMPORARY ' NEW _. REPAIR ❑ OTHER i 0 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 �T it <br /> Type Construction Disposal Site L <br /> i No. of Units 4 Equipment Storage/Cleaning Location(s) t i <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name`. WhereCertigfied € — <br /> Plant Location <br /> Plant Capacity- i Nb. Units Served x N <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 �► L .- <br /> 1,v.r' , <br /> SIZE: El Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> 0 41 <br /> I hereby-certify that I-I av repared this application and that the work will be done In accordance i h Sa quin County <br /> ordinances; state-laws, nd ru an regulations n otaqui Local - atth District. )%CEJ ' <br /> ' • 4 - k gat <br /> .APPLICANT'S SIGNATURE X <br /> rt <br /> r rFOR•DEPARTMENT-USE-ONLY - x <br /> t Fee IS Due: ❑ ANNUALLY't r 01 UNIT ❑ PER SITE ❑ EACH ❑-January 1 &Received By January 31 ❑ July 1 &Received By July.31 . <br /> REMIT <br /> BASEEXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> . <br /> -- DATE DATE REMITTED : AMOUNT <br /> { <br /> r <br /> FEE <br /> LESS <br /> PRORATION'PLUS <br /> e "' {• 1 <br /> PENALTY I <br /> -OTHER <br /> OTHER-_ - .. -. - - ! -• w'' - - [ <br /> Received by Date -Receipt No. Permit No. b `i Issuance Date 'Mailed Delivered- <br /> j .y <br /> APP.0CANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1661 E.HAZELTON AVE.,P.O.BON 2009 STOCKTON,CA 95201 <br />