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TheAppucation. <br /> Applications Will Be Processed When Submitted Properly Completed. Be SureTo Sign <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE' <br /> Applicati s ereby m-le arty on bus' s in the jurisdictional area of ftSan Joaq in Local Health District.) <br />{ Business Name (DBA) �`31' Address <br /> L <br /> zOwner Address <br /> Firm Partners, Addresses and T l p one Numbers <br /> E Business Telephone No. � ��s� Emergency Telephone No. <br /> Contractor Licence No. ��`� Date <br /> Applicants Name (Print) Title <br /> Please check Applicable Category (1-7) and Fill in the Required information J <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, _ June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> GAL. License No. GAL. Licc�se Renewal No. <br /> Serial 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 <br /> No. of Chemical Toilets Stored t <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name <br /> ,. R.S. or R.C.E.No. <br /> I Test Location Test Date/Time <br /> 4.A<SANITATIONPERMIT <br /> Jab Address/ cation <br /> p <br /> Owner Address c❑ C3SEPTEC TANK CESSPOOL � LEACHING FIELD SEEPAG ❑ PACKAGE PLANT <br /> E PIT <br /> JZPERMANENT 11 ❑ OTHER TEMPORARY ❑ NEW REPAIR � <br /> Disposal Site t <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 , <br /> Type Construction {� <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 /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ,f ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> I hereby certify that I have prepared this application aat the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and reOf th ea J �Uinocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BASE - EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE O O .. <br /> LESS <br /> I PRORATION <br /> PLUS { <br /> t PENALTY l <br /> OTHER v + <br /> OTHER <br /> Received by Date Receipt Not -r J Permit No. ISSUanCe Hate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />