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I 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 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUIO WASTE <br /> Appl ication i hereby made t c on b Hess in the ju dictional area of the San Joaquin Local Health Distr � ' <br /> rn Business Name (D f Address <br /> z Owner ddress <br /> I <br /> J Firm Partners, Addresses and Telephone Numbers <br /> Emergency Telephone No. <br /> a Business Telephone No. <br /> Contractor Licence No. Ja _�•'� l <br /> Applicants Name (Print) Title DateQXJ <br /> Please check Applicable Category (1-7) and Fill in the Required Information C} , <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> ti <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 /> i For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> f No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S.or R.C.E.Name <br /> Test tion Test Date/Time <br /> 4. 19 SANITATION PERMIT <br /> Job Address/ cation <br /> Owner Address <br /> 1 ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELDS PAGE PIT 11 PACKAGE PLANT p� <br /> 1:1 PERMANENT ❑ TEMPORARY ❑ NEW 'REPAIR 1:1 OTHER 1 <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 34, 19 <br /> Operator Name Where Certified Ch <br /> l <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 l have prepared this application and that the work will be done in accordan wit n J quin County y� \ <br /> G ordinances, state laws, and rules regulations of the n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> r <br /> I r _ <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11 ANNUALLY El PER UNIT El PER SITE EI EACH 11 January 1 & l�Ce ed By January 31 ❑ July 1 &Received By July 37 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANC $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE j 1. <br /> t <br /> LESS <br /> PRORATION - <br /> F PLUS <br /> PENALTY <br /> OTHER <br /> OTHER h <br /> V <br /> Received by - Dale Receipt No. Permit o, T Issuance Date if - Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,.P.O.Box 2009 STOCKTON,CA 95201 <br />