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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 /> w ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl ication is her by ad' o rry on business in the jurisdictional area of the 5a agyjn cal al Erict <br /> LBusiness Name (DBA) Address <br />'z"a Owner Address <br /> Firm Partners, Addresses and T phone Numbers <br /> a. Business Telephone No. Emergency Telephone No. q' <br /> Contractor Licence No. i <br /> Title Date <br /> LApplicants Name (Print) <br /> I <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 1, June 30, 19 Disposal Sites <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 /> No. of Vehicles Stored t�Q� <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TESTI <br /> R.S. or R.C.E. No. <br /> R.S.or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4SANITATION PERMIT <br /> Job Address/L cation r <br /> Owner Address �- <br /> ❑ SEPTIC TANK ❑ CE POOL ❑ LEACHING FIELD SEEPAGE PI ❑ PACKAGE PLANT <br /> 11 PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> f 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 /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity <br /> No. Units Served l <br /> I <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 <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 I ws, and rules and r gulat' ns of the Sa 7p9joain Local Health District. <br /> /_7 <br /> ° APPLICANT'S SIGNATU EX <br /> t FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 G <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ .AMOUNT DUE CHECKED <br /> - - DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> ` PRORATION <br /> r PLUS <br /> PENALTY <br /> OTHER <br /> OTHER J1 <br /> 9? 7 Issuance Hate Malied Delivered <br /> -" Received by ate _ Receipt o- Permit No, <br /> "1501 E.HAZELTON AVE.;P.O.Boll 2004. STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />