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Applications Will Be Processed When Submitted ProperlyyCompleted. Be SureToSignTneAppacallo". <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> LIQUID WASTE <br /> i <br /> Application 's hereby mad carry on busin in the jurisdictional area of the San JoaquinLoc eal s cta� <br /> yBusiness Nae DBA) Address <br /> z Owner Address <br /> a <br /> j Firm Partners, Addresses and Tel p on! u erg <br /> a Business Telephone No. Emergency Telephone No. <br /> i <br /> �Contractor Licence No. <br /> Applicants Name (Print) <br /> Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) a <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights & Measures No. i <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 W <br /> R.S. or R.C.E. Name R.S. or R.C.E.No. NO <br /> Test Location Test Date/Time V <br /> 4. ❑ SANITATION PERMIT r <br /> Job Addre /Locat� n ✓O�� � �� I � y <br /> Owner I Address r <br /> ❑ SEPTIC TANK ❑ C SPOOL ❑ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ' PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <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 />" fi. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> t 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 /> t ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r , <br /> 1 I hereby certify that,l�t d this application and that the work will be done in accordance with San Joaquin County <br /> { ordinances, state la s, and r les and regulations of the an Joaquin ocal Health District. <br /> 1 <br /> APPLICANT'S SIGNATURE X <br /> f <br /> 1 FOR DEPARTMENT USE ONLY <br /> By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT '❑ PER SITE Cl EACH El January 1 &Received By January 31 C] July 18 fleceiv REMITuIy 3:1 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE . CHECKED <br /> {¢ DATE DATE REMITTED AMOUNT <br /> FEE �€ <br /> LESS / <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receips No. Permit No, Issuance Oate Mailed Delivered <br /> APPLICANT=RETURN ALL COPIES TO'. ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1661'E.HAZELTON STOCKTON,CA 95201� <br />