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Appiications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. y <br /> APPLICATION � <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT 9 <br /> LIQUID WASTE S <br /> Application is hereby made to car on business in the jurisdictional area of the San Joaquin Loc I Health District oC <br /> �;Business N me (DBA) � -. 7 <br /> Address a <br /> z Owner � Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. - Emergency Telephone No. <br /> �i�, - �— <br /> Contractor Licence No. l' f � �� �� <br /> L Applicants Name (Print) V L L I ,U_ Title Q 4 i1111 Date 1 <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 <br /> Description(Make/Yr., Color) x <br /> CAL. L <br /> Serial No. CAL. License No. '€€cense Renewal No. <br /> Capacity +' Gal., Weights &Measures No. 1 <br /> P Y <br /> Equipment Parking Address-� <br /> 2. 0 PUMPER YARD - T, <br /> For.July 1, June 30, 19 ' <br /> No. of Vehicles Stored w , <br /> No. of Chemical Toilets Stored t <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name ' R.S. or,R.C.E. No. - �} <br /> Test kation Test Date/Time . <br /> 4. L� SANITATION PERMIT J' C' <br /> Job Address/ cation 1— <br /> Owner Address l <br /> G�EPTIC T NK 13 CESSPOOL , 'EACHING FIELD 111--SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY L`r 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 Locations} _ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> I Plant Location 0 <br /> Plant Capacity I 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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and i and regulations c a San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X _ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT KPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> - ..- .. - ,-.....--�....� REMIT <br /> BILLING REMITTANCE $ <br /> AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT <br /> 41 i 1 <br /> FEE `7 <br /> LESS <br /> PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1 -� �Issu?nce Dat TBox20019 <br /> Delry red <br /> Received by - Date - Receipt No. -Permit No. r - <br /> ..- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON AVE.,P. STO KTON, 1 <br />