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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 ereby made carryon busin ss in the jur' dictionaI area of the San Joa uin Local Health trict <br /> m Business Name (D ) Address • 7Z'� <br /> i Owner Address `"^ <br /> a <br /> Firm Partners, Addresses anTelephone Num ers <br /> a Business Telephone No. Kr <br /> S— /Q .S Emergency Telephone No. <br /> a3 y� <br /> �Contractor Licence No. - <br /> �Applicants Name (Print} A— Title Date ' <br /> Please check ApplicableCategory(1-7) and Fill in the Requ' edInformation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites I <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. License Renewal 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 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name 4 R.S. or R.C.E. No. <br /> Test L ation � Test Date/Time <br /> 4, lA SANITATION PERMIT <br /> Address/Lo at'on 43 OS- <br /> Job ' <br /> Owner .t� Addresses / ! <br /> V1,F'5 AK <br /> [A-'SEPTIC TANK ❑ CESSPOOL UV <br /> 1 CHING FIELD 'E EEPAGE PIT ❑ PACKAGE PLANT / <br /> ED-'PERMANENT 11 TEMPORARY U"NEW f ❑ REPAIR ❑ OTHER l!" <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 /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 \ n <br /> Operator Name Where Certified �U <br /> Plant Location 40- ` <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> y <br /> I hereby 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 rules and egulations of the Sa aquin Local Health District. <br /> APPLICANT'S SIGNATURE X - <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE []'EACH ❑ January 1 &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 /> FEE <br /> LESS <br /> PRORATION ` <br /> PLUS (� I <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -0 <br /> Received by Date Receipt No. Permit No. Issua c to Mailed Delivere - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCK ON,CA 95241 <br />