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T 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 /> s LIQUID WTE <br /> Application is hereby made to carry on business in the jurisdictional area of-the San Joaquin.Local Health District I <br /> OBusiness Name (DBA) m - Address <br /> z Owner 2-, Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness,.T.elephone No. -Emergency Telephone No. : <br /> Contractor Licence No _ q <br /> a Applicants Name (Print) Title ;Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information ,. „• - ;, H.;L, 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June 30, 19- - Disposal Sites-- ' 1 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> i <br /> 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 <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- Test Date/Time <br /> { 4.t ❑ SANITATION PERMIT <br /> ob Address/Location �J <br /> Owner Addres ` <br /> ❑ SEPTIC TANK ❑ CESSPOOLS ❑ LEACHING FIELD ❑.SEEPAGE PIT P CKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ^THER r�ecj�y <br /> 5. E] CHEMICAL TOILETS For July 1, -June 30, 19 r <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 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity T 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 and regulations of the San Joaquin'Local Health District. r <br /> APPLICANT'S SIGNATURE X _ <br /> - FOR DEPARTMENT U NLY -• <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS V <br /> PRORATION <br /> PLUS I <br /> PENALTY' - <br /> OTHERS- <br /> -OTHER f„� .� <br /> Recesvedb ate Receipt No. Permit No. issue ce'D it Delivered <br /> APPLI ANT-••RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -' 1601 E.HAZELTO , .O-Box 2049 STOCKTON,CA 95201 - <br />