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Applications Will Be Processed When Submitted Properly Complete <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> AQpiication is hereby made to carry on business in the jurisdictional area of the San Joaquin Local e�ahth District <br /> Address <br /> wBusiness Name (DBA) Address <br /> z Owner <br /> C <br /> u Firm Partners, Addresses and Tel phone Numbers /07 Emergency Telephone No. <br /> aBusiness Telephone No. <br /> �Contractor Licence No. �- Title — Date <br /> c Applicants Name (Print) <br /> I Please check Applicable Category (1-7) and Fill in the equired Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOREACHSites <br /> CEHICLE) <br /> For July 1, June 30, 19 _�'� <br /> Description(Make/Yr., Color) CAL. License No. CAt, •Zcense Renewal No. <br /> Serial No <br /> ( Capacity Gal.,Weights-&"Measures`No. tet. <br /> w -- <br /> Equipmeht-Pafkirig 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. 11PERCOLATION TEST R.S:or R,C.E.No. <br /> R.S. or R.C.E. Namea <br /> Test Date/Time <br /> Test Location " <br /> A. ❑ SANITATION PERMIT ,�1dJ 3 ,..�- �Qn,V5�� "' <br /> Job Address/Location /�Jr Address <br /> Owner � �" lJ n ❑ PACKAGE PLANT <br /> 4 4 SEPTIC TANKLEACHING FIELD_ ❑aSEEPAGE`FIT <br /> ❑ CESSPOOL''� =..;.- ❑ REPAIRS --x,,-.. ❑ OTHERr , <br /> t ❑ PERMANENT ❑ TEMPORARY-/ �❑NEWS <br /> 5_ ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ;�..,. <br /> Disposal Site <br /> Type Construction �. <br /> Equipment Storage/Cleaning Locations) <br /> No. of Units . <br /> B• 11 PACKAGE TREATMENT PLANT For July 1,-June 30, 19 Where.Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7, ❑ LAUNDRY For_July 1.,_-.Jupe,30.,�gMore Than 1,000 Sq. Ft. <br /> SIZE: IJ Less Than 1.000 Sq. Ft., . <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo., <br /> •�.� <br /> ork <br /> ! I <br /> ll I hereby-certify that I have prepared this application and that the w the San Joaquin Lal Health done in ccordancewith San Joaquin County <br /> th District <br /> ordinances; state laws, and rules and re at <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY y <br /> ❑ EACH El January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> I fee Is Due: El ANNUALLY ❑ PER UNIT [3 PER SITE REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE' .EXPLANATION DATE DATE REMI ED # AMOUNT <br /> Y D <br /> FEE <br /> ' LESS a <br /> PRORATION j <br /> PLUS <br /> PENALTY <br /> Y <br /> OTHER <br /> OTHER - <br /> ,�, — � - <br /> - - Receipt No. Permit No. <br /> Issuance Date Mailed -Delivered <br /> Received by Date 1601 E.•HAZELTON AVE.,P.O.Box 2009 ,STOGKTON,CA 95204- <br /> 4 TO: ENVIRONMENTAL HEALTH�PERMITISERVICES <br /> APPLICANT—RETURN ALL COPIES <br />