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G Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> n . .' APPLICATION <br /> (For Non-Transferable, Revocable,and Su spendable} SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application ' Thereby made to arry on business in the juri dictional area of the San oaquin Local Health Dista t <br /> V) Business Name ( BA) . Address <br /> zOwner Address <br /> a <br /> R Firm Partners, Addresses and Telephone Numbers <br /> sBusiness Telephone No._ �'5 d S Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> i 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) f <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> I <br /> f No. of Vehicles Stored <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 Dation Test Date/Time <br /> 4. Z SANITATION PERMIT <br /> Job Address/Coca 'on i <br /> O_w �� Address eP <br /> L! SEPTIC TANK ❑ CESSPOOL Ll° LEACHING FIELD ❑ ,IT ❑ PACKAGE PLANT <br /> 11 PERMANENT ❑ TEMPORARY ❑ NEW PAIR 13 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 C' <br /> Type Construction Disposal Site — <br /> No, of Units Equipment Storage/Cleaning Locations) <br /> I 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <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 and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules a regulations of theAn Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH , ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEBy July 31 <br /> RASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE _ CHECKED <br /> - DATE DATE REMITTED A OUNT <br /> FEE <br /> LESS <br /> PRORATION [� <br /> PLUS C1 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7 do-7 1 G V <br /> Received by Date Receipt No: Permit No Issuan pate Mailed Delivered <br /> - - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 150tf.-HAZELTON AVE.,P.O.Boa 2009 BTOCKTON,GA 95201 <br />