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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 ' Aeby made o arrypw-�si jgss in the jurisdictional area of the San.Joaquin Local. ealth District <br /> OF Business Name DBA) Address �2p-,Z7- <br /> z Owner Fes ` < Address - <br /> a Y . <br /> J Firm Partners, Addresses and Telephone N tubers <br /> CIL Business Telephone No.. 4 - Emergency Telephone No., ; <br /> Contractor Licence No. �^ 1 <br /> Applicants Name (Print) y` - _ Title I Date <br /> a �.. . <br /> Please check Applicable Category (1-7)and.Fill in the Required Information ., r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 41 <br /> For July 1, -- June 30, 19, Disposal Sites - <br /> Description(Make/Yr., Color) <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 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. ANITATION PERMIT ) <br /> Job Address/ ocat'on <br /> Owner CS zo Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ;W--6EACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT 5. <br /> ❑ PERMANENT ❑ TEMPORARY a ❑,NEW 04,EPAIR ❑ OTHER s <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <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 r <br /> e <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. UJ <br /> ElDRY CLEANING, Chemicals Used/Amount/Ma. <br /> I hereby certify that I have epar ' thi 'pplic i an at the wo k will be done in accordance with San Joaquin County' <br /> ordinances, state laws, a rut nd lat' s the n Joaquin ocal 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 I &Received By July 31 <br /> REMIT <br /> BILLING RE NCE S <br /> BASE EXPLANATION .DATE TE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE `T1 <br /> LESS <br /> PRORATION - <br /> PLUS J _ <br /> PENALTY <br /> OTHER <br /> OTHER_ - <br /> Received by Date Receipt No. Permit No, +, Ibsuaribe Da ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES =- 1601 E.HAZELTON AYE., .Box 9009 STOCKTON,CA 95201 ,I <br />