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Applications Will Be Processed When Submitted'roperly Completed.Be Sure To SignTheApplication. <br /> APPUCATiON <br /> (For Non-Transferable,Revocable,and Suspendable) aW H _.SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District f <br /> Ad ess <br /> Business a (DBA) <br /> _U t G Address <br /> r Owner <br /> a <br /> Firm Partners, Addresses an T Ie hone Numbers Emergency Telephone No. <br /> 0, Business Telephone No. <br /> -i Contractor Licence No. Title Date <br /> Applicants Name (Print) <br /> 1 7 and 11 In the Required Information <br /> Please check Applicable Category ( - ) 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I <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. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, -` - ` June 30,-19 -- 1 <br /> aI No.of Vehicles Stored € y { �` <br /> Itf No. of Chemical Toilets Stored w�_ <br /> 1 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. • <br /> 1111 R.S. or R.C.E. Name - <br /> Test-Location Test`Date/Time <br /> 4. SANITATION PERMIT <br /> Job Addr /Locatio t <br /> Owner �� w Address <br /> ❑ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT i <br /> 01 SEPTIC TANKr' C],.0 SSPOOL OTHER <br /> ❑ PERMANENT �� TEMPORARY 11 NEW REPAIR <br /> 5. 11 CHEMIC AL.TOILETS For July 1, -June 30, 19 <br /> 4 Type Construction`. Disposal Site <br /> ;.- _ ! Equipment Storage/Cleaning Location(s) <br /> ts> <br /> No. of Uni __ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name ' '3 <br /> Plant Location <br /> 1 No. Units Served <br /> Plant Capacity <br /> k 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 /> L hereby certify that I <br /> ha repared t Is app cats n and that the work will be done in accordance with San Joaquin County T <br /> ordinances, state laws, an r les an�'r g lati ns o the.San Joaquin Local Health District. <br /> APPLICANT'S SIGNATUREX._ <br /> FOR DEPARTMENTUSEONLY <br /> ." -- -- - -Y �❑ Januar 1 &Received By January 31 ❑ July 1 &Received B 31 <br /> I#- Fee(S Due'❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH y REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE, ATE REMITTED AMOUNT <br /> - yS <br /> FEE <br /> 1 LESS <br /> 1 PRORATION -- <br /> Yr <br /> i PLUS ' <br /> f PENALTY <br /> t <br /> OTHER <br /> OTHER` "s <br /> ate Receipt No. Permit No. I suan a Dat Mailed DelC 85201 <br /> d <br /> }t Received by 1601 E.NAZELTON AVE.,P.O.Box 2009 STOCKTON;CA <br /> 1 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES <br />