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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign tnepppncauun. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH,PERMIT 11(1 <br /> LIQUID WASTE 1 <br /> Application is hereby made to carry on business-in the jurisdictional area of the San Joaquin Local Health Dis .ict {1 <br /> HBusiness Name (DBA) � � �«' =d'�J Address <br /> Address \ <br /> a Owner <br /> j Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No: - S ?7/- Emergency Telephone No. <br /> Contractor Licence No. 2.. <br /> Applicants Name (Print) <br /> Title 6 fiJ✓� Date <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 11 June 30,'•19 >` - Disposal Sites F - <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License 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 /> 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. . Y_ <br /> Test Location Test Date/Time U <br /> 4. �SANITATION PERMIT T Ni <br /> JoAddress/Location �� <br /> Owner SP'K Address <br /> 4 ❑ PACKAGE PLANT <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD �SEEPAGE P1T <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER_ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> I. Type Construction Disposal Site <br /> I No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,004 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaq <br /> puin County <br /> ordinances, state laws, and rules and regulat. ns of the Sa oaquin Local Health District. <br /> r APPLICANT'S SIGNATURE X - <br /> w - ... -FOR DEPARTMENT USE ONLY <br /> Fee IS Due, ❑ ANNUALLY PER UNIT PER SITE EACH 13 January 1 8 Received By January 31 ❑ July i &ReceivedREMITuIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY I - <br /> OTHER �/ ! <br /> OTHER <br /> Received by Date Receipt No. Permit No issuance Date Mailed De Iver d <br /> 09 STOCKTON,CA <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.Q.box 20 <br />