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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 /> ENVIRONMENTAL HEALTH-PERMIT , <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area:of the San Joaquin:Local Health District-, a � <br /> rn Business Ne {DBA) Address <br /> r AddreSS <br /> z Owner - <br /> J Firm Partners,Addresses and Telephone Numbers , <br /> CL Business Telephone No. Emergency Telephone Now <br /> 1 Contractor Licence No. <br /> Applicants Name (Print) �� U./✓ lr-L Titl1.e' e2 -Date j� <br /> r <br /> Please check Applicable Category(1-7)and.Fill in'the Required Information.-t, ::1b -_' r- <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Forluly•1 --L-- _.June•30, 19-1- Disposal Sites—­L_- - _ <br /> - - <br /> Description(Make/Yr., Color)- <br /> Serial No. CAL. License No. CAL. License Renewal No. . <br /> . b- <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 <br /> .3. ❑ PERCOLATION TEST ` <br /> t R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> ' Test Location Test Date/Time <br /> 4. SANITATION <br /> PER ' <br /> Job Addr_ess/Locations ' <br /> 0 er�' Address <br /> uSEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1_-June 30, 19 <br /> .Type Construction -r Disposal Site <br /> No. of Units Equipment Storage/Cleaning:Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> l Operator Name ' Where Certified <br /> Plant Location V <br /> 'Plant Capacity a No. Units Served U <br /> 7.,❑ ;LAUNDRY . For July 1; -June 3019-----ri G <br /> ,SIZE: El Less Than 1,000 Sq`. Ft.,- ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. w t <br /> T. <br /> �. . - , <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an rules and regulati s of the San Joaquin Local Health District. <br /> { APPLICANT'S SIGNATURE X <br /> -FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION - BILLING REMITTANCE :$ AMOUNT DUE CHECKED <br /> - DATE - DATE REMITTED - AMOUNT <br /> . t �� (0 � <br /> FEE � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY Z ' <br /> OTHER <br /> OTHER - - <br /> 62 <br /> Received by Oate Receipt No. Permit No. Issuance Date Mailed .Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16011 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA 95201 <br />