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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. -. 4 <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i ereby mad to carry on usin ss in he ju(yysdictional area of the n JZin Local Health Distwt <br /> OF Business Name A) Address <br /> aOwner _. Address <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CIL <br /> Business Telephone No. 3G8 Irl d -r Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) r' Title <br /> -a'a— Date <br /> Please check ApplicableIFCategory (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July,1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity. r 1 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 R.S. or R.C.E. No. <br /> Test LLation Test Date/Time <br /> 4. 15 SANITATION PERMIT <br /> 1 �7 <br /> Job Address/Loc ion � � � _.� V <br /> Owner <br /> Address� 3 7 Y `'a w <br /> 11 SEPTIC TANK ❑ CESSPOOL I- <br /> LEACHING FIELD SEEPAGE PIT; ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW �!{EPAIR ❑ OTHER <br /> I <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 l <br /> Type Construction Disposal Site Z <br /> No. of Units Equipment Storage/Cleaning Location(s) OF <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 T <br /> t r <br /> Operator Name Where Certified <br /> Plant Location <br /> V <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., J-❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordfnFwith San Joaquin County <br /> ordinances, state laws, and rules and gulativns of the San Joaquin Local Health District. V) <br /> APPLICANT'S SIGNATURE X CzJj �J <br /> i <br /> FOR DEPARTMENT USE ON Y <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January ceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITT CE $ AMOUNT DUE CHECKED _ <br /> DATE DAT REMITTED AMOUNT - <br /> FEE f <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> V <br /> Received by Date - Receipt No. Permit No, Issuance Date Mailedf Delivered <br /> APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1901 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 85201 <br />