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y'1 Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION t <br /> (For Non-Transierable, Revocable,and Suspendable) %+ <br /> -` ENVIRONMENTAL HEALTH PERMIT - SEPTAGE V <br /> LIQUID WASTE. _ <br /> Application is her to ca bu.,gines the jurisdictional area of the San J juin Lo ealth District <br /> rn Business.Name A) d ddress Y Z 1 <br /> aOwner_ w Address Firm-Partners, Addresses and Telepne Number <br /> 4 Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> AppGcantS Name (print) C Titled Date Z O <br /> Please check Applicable Category (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 "U <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. i <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 t <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Loca Test Date/Time _ <br /> 4. ANITATION PERMIT U <br /> Job Address ocation <br /> Owne Address __ <br /> S IC TANK CESSPOOL EACHINIS FIELD SEEPAGE PIT r <br /> ❑ ,-, - ❑ PACKAGE PLANT i <br /> ERMANENT ❑ TEMPORARY M-K'EW_ 11 REPAIR ❑ OTHER �1 p <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 34 19 ' <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) . i <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name - Where Certified <br /> Plant Location s F <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,040 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <br /> I hereby certify that I have prepared this application and th -the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r les and regulations oft Sa J a in Local Health District. <br /> APPLICANT'S SIGNATURE. <br /> .�• x.�. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 0 EACH ❑ January 1 &-Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT ' <br /> e - BILLING REMITTANCE - $ _ ' <br /> r _ BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> MOUNT_ <br /> of i i <br /> FEE <br /> LESS <br /> PRORATION Irl <br /> PLUSH:. � � � <br /> PENALTY <br /> OTHER 1 y <br /> OTHER '� - ` U• <br /> Received by _ Date Receipt No. Permit No. nuance Date Mailed Delivered -� <br /> - r <br /> APPLICANT—JAETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 16111 E.."HAZELTON-AVE.,P.O.Bo=2009 STOCKTON,CA 95201 <br /> .A <br />