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F Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheAPPucarlon. <br /> k _ APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> t AppliAddress -2 f <br /> Address <br /> catio isJ lereby made to carry o b siness in the jurisdictional area of the San Joaquin Local Health District +�L <br /> ,,*� � <br /> FBusiness Name Dia <br /> - za Owner <br /> Firm Partners, Addresses and Telep o mbers <br /> �. Emergency Telephone No. <br /> 0.a Business Telephone No. <br /> f �--- <br /> Contractor Licence No. <br /> }° . � Title o <br /> Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information .J <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. GAL. License No. <br /> Capacity Gal. Weights &Measures No. <br /> i Equipment Parking Address <br /> G 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 R.S. or R.G.E. No. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location <br /> I <br /> caner /` rddress <br /> SEPTIC TANK ❑ CESSPOOL L ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT YSt <br /> } ,X PERMANENT ElTEMPORARY NEW <br /> El REPAIR C] OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> $, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified a <br /> Operator Name <br /> F Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 y <br /> SIZE: <br /> ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t — <br /> �rT <br /> l <br /> G 1 hereby certify that 1 have prepared this application and that the`work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an ale nd regulations of the S Joaq 'n Local Health District. <br /> i APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juty 1 &Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT REMIT <br /> BILLING REMITTANCE $ AMOUNT.DUI= CHECKED <br /> ,BASE EXPLANATION x DATE -+ -^*M+r 'DATE REMITTED AMOUNT <br /> L FEE df <br /> LESS <br /> PRORATION <br /> PLUS rtJ� <br /> PENALTY <br /> OTHER ' �. <br /> OTHER <br /> i% Received by <br /> Oat Receipt No, - Permit No. ISsuan a Date Mailed Deliver <br /> 1601 E.HAZELTON Ave.,P.O.Box 208 STOC ON,CA 520 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 'i, . - ... <br />