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Applications Will Be Processed When Submitted Properly Completed. Besure Iosign InuKppuwauein. <br /> r 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 th�pSan Jo�jquin Local Health District <br /> Business Name (DBA) �- j h Address_ •Q• l'ak� 1Co� <br /> aOwnerj�-7t^ r _P Address <br /> 0 Firm Partners, Addresses and Telephone Numbers <br /> a (P - O Emergency Telephone No. <br /> n. Business Telephone No. <br /> a 4Cgory <br /> ZZ <br /> Contractor Licence No, <br /> L Applicants Name (PrintTitle V, Date Z ` <br /> Please check Applicabl (1-7)and Fill in a Required Information �! <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 04 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. _ CAL. License No. CAL. License Renewal Na. <br /> Capacity— Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD f <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�Lo�tion Test Date/Time <br /> 4. t1 SANITATION PERMIT <br /> Job Add re,,s/Location z I E <br /> Owner r AC'r Address qo <br /> ❑ SEPTIC,TANK 11 CESSPOOL 13 LEACHING FIELD 9F EPAGE PIT ❑ PACKAGE PLANT <br /> ❑ OTHER � <br /> 11 PERMANENT ❑ TEMPORARY 11 NEW M�-grPAIR p� <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 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> i 7. ❑ LAUNDRY For July 1, -June 30, 19 �} <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. t�J <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 accordance with San Joaquin County <br /> ordinances, state laws, an rules and reSan Joaqal Health District. <br /> �Iab �ollhe uin Loc <br /> 11 APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ,J❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January Y &Received By January 31 ❑ July 1 &ReceivePdEMIT By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE. <br /> L <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> Y OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss ance�Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEAMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> recd /014, DCS <br />