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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> APPLICATION <br /> t' (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT /� <br /> LIQUID WASTE �trf �� <br /> Applicati is hepy ma to rryon usiness in the jurisdictional area of the San Joaquin Local Healt istrict r I <br /> UF) Business Na�J�DB <br /> 17. o Address e� J <br /> i Owner S ® Address <br /> C <br /> J Firm Partners, Addresses and Telephone Numbers } <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. r 4r <br /> Applicants Name (Print) <br /> Title Date <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) 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 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Tet Location Test Date/Time <br /> 4. )i SANITATION PERMIT [�]� <br /> Job Addres /L c Ion <br /> Owner Address <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 13 SEEPAGE PIT C1 PACKAGE PLANT Go <br /> ❑ REPAIR ❑ OTHER 0 <br /> I <br /> 11 PERMANENT E] TEMPORARY ❑ NEW p <br /> 4 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 V� <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. 13 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location 01 <br /> Plant Capacity 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 I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> { APPLICANT'S SIGNATURE X <br /> # FOR DEPARTMENT USE ONLY <br /> MBy <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE EACH ❑ January 1 8 Received By January 31 E3 July 1 &ReceiveRdEMITuIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS !1 <br /> PRORATION - - <br /> PLUS <br /> ' PENALTY <br /> OTHER <br /> OTHER r <br /> M �� -lg <br /> Received by <br /> D 1 Receipt No. Permit No. Issuance Date ail Delivered <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE., Bo 009 STOCKTON,CA 95201 <br /> . <br />