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^ � Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> (For Non-Transterable,-Revocable,and Suspendable) <br /> SEPTAGE <br /> 0d ENVIRONMENTAL'HEALTH PERMIT <br /> r LIQUID WASTE <br /> Application is hwqqy madato rry on by4sAiness in the jLAqcliCtional area of t an oaqu�LocalHealth tr AlJ <br /> rn Business Name (DBA) • Address <br /> f <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and TelephflIF pf 1+ erp <br /> 0, <br /> abusiness Telephone No.— ' ffee // n 7 Emergency Telephone No. <br /> Contractor Licence No " - l <br /> Applicants Name (Print) Title Date• 1 <br /> a', r <br /> Please check Applicable Category (1-7)and'Fill in the Required information s r «s <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ,X <br /> For July 1, June 30,19-— Disposal Sites a <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 Vehicle;p Stored <br /> No. of ChemicallToilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E.No. <br /> R.S. or R.C.E. Name <br /> Test Date/Ti <br /> Test Location me <br /> 4. SANITATION PERMI ,. h <br /> Job Address/Location �� <br /> Owner b Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD :❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 'PERMANENT 1:1TEMPORARY NEW :F. .-%;,'❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ~t . <br /> Type Construction Disposal Site' i <br /> C.s <br /> No. of Units Equipment Storage/Cleaningocation(s) <br /> B• ❑ PACKAGE TREATMENT PLANT' For July 1; -June 30, 19 Where Certified. <br /> Operator Name t <br /> Plant Location c <br /> No. Units Served, <br /> Plant Capacity <br /> . <br /> 7 ❑ LAUNDRY For July 1, -June 30, 19 <br /> s !' <br /> er Ft.,, ❑ More Than 1,000 Sq. Ft. <br /> SIZE: © Less Than 1,040 Sq. _ - , - <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. V}# <br /> Ihereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule and regulatio s of this oaquin Lo 1 Health District. <br /> APPLICANT'S SIGNATURE X ,sE <br /> r s <br /> FOR DEPARTMENT USE;ONLY <br /> Fee Is Dile: El ANNUALLY i_ ❑ PER-UNIT: ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEBy July 31 <br /> ' MIT <br /> BASE _ EXPLANATION- BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> _ DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> ' PENALTY <br /> pill <br /> OTHER <br /> C I <br /> OTHER <br /> �suane <br /> a e Mailed De4ivered 1 <br /> Received by , • Date Receipt No. rm'it No. <br /> _ •1601 E.HAZELTON AVE.,P.O.ao=2009 STOCKTON,CA 95201 <br /> "APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />