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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) <br /> SEPTAGE f <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Y Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> N Business Name (DBA)—45 9fd&s Mile- Address <br /> a Owner <br /> Address <br /> zu Firm Partners, Addresses and Telephone Numbers ti <br /> aBusiness Telephone Na. K-" -9 71 Emergency Telephone No.-. <br /> 3 Contractor Licence No. <br /> r Applicants Name (Print) age Title.4., Date <br /> Please check Applicable Category (1-7),and Fill in the Required information .. y <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,� June-30, 19 - _ Disposal Sites <br /> p - r <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 of Vehicles Stored <br /> No. of Chemical Toilets Stored f <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 - g <br /> 4. 0 SANITATION PERMIT ; r t4 t `i 4 <br /> Job Address/Location ' s 4r,>2�' S ✓� <br /> Owner �~ Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL .� LEACHING FIELD J9 SEEPAGE PIT o- ❑ PACKAGE PLANT - <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ® REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 -� <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19.E !� x .. <br /> Operator Name '= vim=_ Where Certified <br /> Plant Locatiori`3. r - ` <br /> Y �V - <br /> Plant Capacity i- <br /> I No. Units Served <br /> 7. ❑ LAUNDRY' For July 1, -June 30, 19 _ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 9❑•-More�Than 1-000.5q;Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ° <br /> f . . <br /> I hereby certify that I have prepared Phis'application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of an Joaquin Local Health District. r <br /> APPLICANT'S SIGNATURE X t _ <br /> FOR'DEPARTMENT USE ONLY' y <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT _❑ PER SITE ❑ EACH ❑ January i &Received By January 31 0 July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> E DATE DATE REMITTED AMOUNT <br /> e <br /> FEE f. <br /> LESS 1 1 <br /> PRORATION -; <br /> PLUS 33 / <br /> PENALTY <br /> OTHER 7 <br /> OTHER <br /> s � <br /> it Received by Dat eReceipt No: - rmit No. Issu nce Date Mailed Delivered _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AV .,P.O.Box 2009 $TOCKTON,CA 95201 <br />