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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) j SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT J <br /> LIQUID WASTE f <br /> Applications is hereby made to carry on business in the jurisdictional area of the San Joaquin,Local Health District <br /> y Business Name (DBA) GAddress _ - <br /> . <br /> aOwner - -,Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL Business Telephone No. Emergency Telephone No. b <br /> Contractor Licence No. <br /> LApplicants Name (Print) Title; Date 1 <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 r°�^. June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) 1 ^� <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' <br /> No. of Vetlicles Stored 3 <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location 1 Test Date/Time <br /> 4. ❑ SANITATION PERMIT ! (�� —5 <br /> Job Address/Loc tion <br /> Owner � Address <br /> ❑ SEPTIC Y ANK ❑ CESS OL ff LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANTo� <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ kEPAIR ❑ OTHER V <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 I "~ <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 3Q 19 LJ V <br /> Operator Name y <br /> I l ��- ,Where Certified <br /> Plant Location t Ft <br /> Plant Capacity No. Units'Served ^_► A <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 } <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 1 7 <br /> I hereby certify that.l have prepare this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and,rdles and regulatio of the San Joaqui Local Health District. <br /> + `, ,- � 1� <br /> APPLICANT'S.51GNA PURE X"' . <br /> '- <br /> I , <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT, - ❑ PER SITE ❑ EACH ~-� January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE- DATE REMITTED <br /> AMOUNT <br /> FEE,. "q � „ rl�� - <br /> 40 <br /> LESS <br /> PRORATION <br /> i <br /> PLUS r� <br /> PENALTY - ✓ " <br /> OTHER <br /> OTHER n { <br /> Received by Date - .Receipt No. Permit No. Iss ante ate Mailed Delivered . <br /> APPbCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Bac 2009 STOCKTON,CA 95201 <br />