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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 5uspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati is ereby a to garry on siness in the jurisdictional area of t�Sanoaqui �al t ict <br /> N Business Narne (DB ) <br /> Addre <br /> z Owner Address <br /> a <br /> 2 Firm Partne s, Addresses and Telephone Numbers <br /> a = 6 Emergency Telephone No. <br /> a Business Telephone No. <br /> a <br /> Contractor Licence No. -3 " U 1 <br /> Title Date r� <br /> Applicants Name (Print) lJ l <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> 5 <br /> For July 1, June 30,.19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Lion. se Renewal No. I <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address i <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. .S. or R.C.E. No. <br /> .S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> 4. WSANITATION PERMIT .. <br /> Job Addr /Loc ion (f(� <br /> Owner Address <br /> I�CSEPTIC TANK 13CESSPOOL 11LEACHING FIELD 13SEEPAGE PIT '0 PACKAGE PLANT <br /> OPERMANENT ❑ TEMPORARY ❑ NEW XREPAIR ❑ 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 /> 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 /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., El More Than 1,000 Sq. Ft. <br /> I` ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> II 1 <br /> Ik 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, ales and regulations of the an Joaquin Local Health District. f <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 /> SASE EXPLANATION SICCING REMITTANCE MOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE y4? <br /> LESS �V <br /> PRORATION <br />{ PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Is uance to Mailed Delivered <br /> �`_ -APPLICANT=-RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH PERMIT/SERVICES - 1601 E.HO „P.O.-Box 2009 STOCKTON,CA 95201 <br />