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- "° Applicatlofs 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 /> Appl ication i by ade t rry on usiness' the jurisdictional area of the Sa oaqui ocal Health District <br /> // <br /> F Business Name(DBA) �� �/�� Address . <br /> i Owner 4. r— Address <br /> j Firm Partners, Addresses.and Telephone Numbers <br /> E Business Telephone No. 4 5 - Emergency Telephone No. <br /> Contractor Licence No. 4` <br /> �Applicants Name (Print) 'i t Title Date <br /> Please check Applicable Category(1-7) and FI11 in the Required Information .s v <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 /> Capacity 4 Gal., Weights & Measures No. <br /> Equipment Parking Address IIM <br /> 2. ❑ PUMPER YARD ��' <br /> For July 1, June 30, 19 ' 1� <br /> No. of Vehicles Stored hM <br /> No. of Chemical Toilets Stored ,�/ <br /> 3. ❑ PERCOLATION TEST �� I <br /> R.S. or R.C.E. Name _ R.S. or R.C.E. No. <br /> Test Location ~t� Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Loction GJ <br /> caner I Address '- 4� <br /> SEPTIC TANK ❑ CESSPbOL LEACHING FIELD 0 SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHER <br /> ❑ CHEMICAL TOILETS For July 1, -rune 30, 19 <br /> Type Construction �N Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT r�LANT For July 1, -June 30, 19 <br /> Operator Name I�E Where Certified <br /> Plant Location <br /> Plant Capacity No Units Served <br /> r 7. ❑ LAUNDRY For-July 1j,-'eJune 30, 19 <br /> SIZE: ❑ Less Than 1,000 SglFt., ❑More Than 1.,000 Sq. Ft. .� <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 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 and rules nd r ulatio of the San Joaquin Local Health district. <br /> APPLICANT'S SIGNATURE X- i� . .. � r I ' <br /> t FOR DEPARTMENT USE ONLY <br /> Y Fee Is Due: ❑ ANNUALLY f__❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> 1� AMOUNT <br /> FEE 5, O ap <br /> LESS I� <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER II <br /> OTHER <br /> -I l -r meg, <br /> Received by Date Receipt No. Permit No Issuance D t Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />