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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> `a APPLICATION <br /> (Far Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> r Application here y m�e to carr o busiPe w theme jurisdi tional area of th an quin Loca�,eaI h Di rict <br /> Business Name (DBA) r � ..Address49 (J <br /> z Owner Address € <br /> a <br /> J Firm Partners, Addresses and Tie hon u bers <br /> 0. Business Telephone No. Gf(� — Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date l� <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 011 <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. l <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> i <br /> No. of Chemicai Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Test ovation Test Date/Time <br /> 4. SANITATION PER IT I, <br /> Job Addr /Location 7 r <br /> Owner Address <br /> SEPTIC TARK ❑ CESSPOOLLEACHING FIELD SEEPAGE PIT ❑ PACKAGV PLANT <br /> PERMANENT ❑ TEMPORARY K NEW 11REPAIR 0THER-J&P1144E j'X 6h#Ja STT IV1 tnl <br /> S. ❑ 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 <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. j <br /> Wde <br /> I hereby certify that I have prepared this ap lication and that the work will be done in accordance with San Joaquin County 1 <br /> ordinances, state laws, i9es an re ul rtns of the aqui al Health District. <br /> i <br /> APPLICANT'S SIGNATURE X c ) <br /> 1/7 <br /> FOR DEPARTMENT USE ONLY x <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 OUE ECKED <br /> DATE DATE REMITTED MOUNT <br /> FEE J �s <br /> LESS i <br /> PRORATION (7 <br /> PLUS ✓1 l <br /> PENALTY /' - <br /> OTHER <br /> OTHER <br /> b T j Ct '7110-S6 . - o-Ra r <br /> Received by Date Receipt No. Permit No I Issu nce Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: _ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE., .So,20D9 STOCKTON,CA 95201 <br />