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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 Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application iv9reby made carrrry(&n bu�sir�ess i the jurisdictional area of thran oaquinLorra1 Heal Distr ct <br /> OF Business Name (DBA) -�Yi • Address •Q� <br /> aOwner Address <br /> 1 Firm Partners, Addresses and Tele hone Numbers <br /> aI Business Telephone No. —.�y�� ` Emergency Telephone No. - t <br /> 1 Contractor Licence No. <br /> LApplicants Name (Print) Title. Date T <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) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> fi <br /> Capacity Gal.,Weights & Measures No. <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 ' r <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Telcation Test Date/Time <br /> 4. Pt SANITATION PER IT f1 <br /> Job Addre /Location V <br /> Owner _ �✓ �- Address <br /> ❑ SEPTIC TANK ❑ CESSPOOLLEACHING;FIELD - ❑ SEEPAGE PiT ❑ PACK E PLANT <br /> ❑ PERMANENT ❑ TEMPORARY l❑ NEW X REPAIR '❑ OTHER n a <br /> 5. ❑ CHEMICAL TOILETS For,.- <br /> July 1—, -June 30, 19 <br /> ` <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 /> Operator Name Where Certified , <br /> Plant Location <br /> Plant Capacity } ) No. Units Served <br /> 7. ❑ LAUNDRY For July 1,.-June 30, 19 ' A <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., El Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> u <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, an ules a d r lation the San Joaquin Local Health District. <br /> 1 ► §. r <br /> APPLICANT'S SIGNATURE X c <br /> x <br /> t 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 /> i REMIT <br /> ,BASE EXPLANATION <br /> "BILL <br /> REMI CE $ x AMOUNTDLIE ,CHECKED <br /> .t� DAT.E.,-..:;+. - REMITTED AMOUNT <br /> r FEE <br /> f` LESS . t . <br /> PRORATION ` s <br /> r PENALTY <br /> PLUS <br /> r e <br /> OTHER t <br /> OTHER <br />}� Recei by Date Cl Receipt No. - Permif No. - issuance ate Mailed Delivered <br /> APP CANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />